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PRESENTED BY 



MONOGRAPHS. OF 

THE ROCKEFELLER INSTITUTE 

FOR MEDICAL RESEARCH 

No. 16 May 10, 1922 

TYPHOID CARRIERS AND TYPHOID IMMUNITY 

Omnis Typhus ex Typho 

By 

ABRAHAM L. GARBAT, M.D. 




NEW YORK 
The Rockefeller Institute for Medical Research 

1922 

Made in the United States oj America 



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Copyright, 1922, by 
The Rockefeller Institute for Medical Research 



WAVERLY PRESS 

The Williams & Wllkins Compahy 

Baltimore, U. S. A. 




MONOGRAPH No. 16 — ; , , ~ 

'fab 



TYPHOID CARRIERS AND 
TYPHOID IMMUNITY 



BY 
ABRAHAM L. GARBAT, M.D. 




NEW YORK 
The Rockefeller Institute for Medical Research 

1922 













O " "* *X 



MONOGRAPH OF THE ROCKEFELLER INSTITUTE FOR MEDICAL RESEARCH, NO. 16, 

MAY 10, 1922. 



TYPHOID CARRIERS AND TYPHOID IMMUNITY.* 
Omnis Typhus ex Typho. 

By ABRAHAM L. GARBAT, M.D. 

(From U, S. A. General Hospital No. 12, Biltmore, N. C, and the Lenox Hill 

Hospital, New York.) 

(Received for publication, July 7, 1919.) 
CONTENTS. 

I. Introduction and General Considerations. 

Importance of the carrier problem in civil life and in the army ... 3 

Origin of the epidemic ." 4 

Endo's medium: its preparation and use 5 

Division of typhoid illness into two stages 6 

II. Duodenal Cultures Versus Feces Cultures as a Means of Detect- 
ing Carriers. 

History of the "typhoid carrier problem" 8 

Technique for obtaining bile 9 

Characteristics of bile specimens 10 

Technique for bacteriologic examination 11 

Unreliability of feces examinations for detection of typhoid 

bacilli; accuracy of bile cultures 11 

Constancy of positive bile cultures 14 

Use of stool cultures for detection of certain carriers 21 

Types of bacteria other than typhoid found in the bile 22 

Typhoid Feces Carriers, with Special Reference to a Classifi- 
cation of the Various Types and Their Surgical Treatment. 

Classification of types of feces carriers 24 

Frequency of various types 25 

Diagnosis of intestinal carriers 27 

Diagnosis of bile carriers 30 

Ascending infection of the gall bladder and bile ducts 37 

Surgical treatment of carriers 41 

IV. Predisposing Factors to the Typhoid Carrier State with Special 
Reference to Cholecystitis and Cholelithiasis. 

Cholecystitis 47 

Pathology of the gall bladder in carriers 51 

Cholelithiasis 51 

* This essay was awarded the Cartwright Prize by the College of Physicians 
and Surgeons, Columbia University, June 4, 1919. 

1 



2 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

V. Typhoid Urine Carriers. 

A. Irregularity and Intermittency of Bacilluria; New 

Method for Detecting Urine Carriers 55 

Accurate method for detecting typhoid bacilli in urine. . . 70 

B. Character of Urine; Origin and Frequency of Carriers. 

Importance of typhoid urine carriers 72 

Chemical properties of urines containing typhoid bacilli. . 73 

Source and origin of typhoid bacilluria 76 

Classification of urine carriers 80 

VI. The Complement Fixation Test for Typhoid Fever. Statistical, 
Clinical, and Experimental Studies. 

Complement fixation test during typhoid convalescence 82 

Factors accounting for the persistence of a positive test 84 

The complement fixation test in carriers 87 

Experimental studies to prove the origin of the complement fixa- 
tion bodies 89 

Comparison between Widal test and complement fixation test 

during convalescence 92 

The complement fixation reaction as a diagnostic test during 

convalescence 93 

Technique of the complement fixation tests 100 

Conclusions 104 

Bibliography 108 






I. INTRODUCTION AND GENERAL CONSIDERATIONS. 

Importance of the Carrier Problem in Civil Life and in the Army. 

In spite of our increased knowledge of typhoid prophylaxis, typhoid 
fever is still a disease to be reckoned with. In the army the generalized 
use of antityphoid inoculations has undoubtedly prevented the occur- 
rence of large and serious epidemics; but isolated instances and small 
outbreaks (1) are still frequent. While official reports with the accu- 
rate numbers of cases of typhoid infection among the 2,000,000 men 
in the American Expeditionary Forces are not as yet available, the 
total will be below 2,000 cases. It is important for patients to realize 
that antityphoid inoculation per se is not an absolute safeguard against 
typhoid infection and that the observation of the other prophylactic 
measures is therefore necessary. Failures of vaccination to protect 
against the disease are in some instances explained by "mass infection;" 
i.e., the patients imbibe so large a number of bacteria at one time that 
the antibodies obtained by previous prophylactic injections are not 
sufficient to overcome the bacilli. In other patients, the disease may 
arise because the prophylactic inoculations do not stimulate the pro- 
duction of immune bodies. This failure of the tissue cells in certain 
individuals to react, is well known, and can usually be proven by the 
absence of agglutinating antibodies in the blood. A Widal test should 
therefore be made on every person receiving antityphoid inoculations. 
Whereas if antibodies have been stimulated it does not necessarily 
follow that a patient is sufficiently immune, it is highly significant of 
lack of immunity if the Widal test remains negative. 

Other factors, such as impotent vaccine, improper technique of 
inoculation, or infection by a special strain of organism, may also 
account for failure of adequate protection. 

In civil life, typhoid fever continues to merit even greater con- 
sideration. 

According to Gay (2), this disease remains the ninth contributing 
cause to the mortality statistics in this country and ranks fifth among 
the infectious diseases, being exceeded as a cause of death only by 

3 



4 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

tuberculosis, pneumonia, infantile diarrhea, and diphtheria. Even 
as recently as in 1919, the death rate from typhoid in certain locali- 
ties was as high as 58.4 per 100,000 of the population (3). Although 
the average mortality of typhoid is usually given as 8 to 10 per cent, 
this percentage is much higher in some cities than in others; in one 
town, out of 281 cases there were 49 deaths, and in another, out of 
35 cases there were 7 deaths. About 150,000 typhoid cases still occur 
each year in the United States, and this causes an annual production 
of approximately 7,500 carriers. When one realizes that according to 
some statistics (4) as many as 44 per cent of all typhoid cases are due 
to carriers, the economic importance of the carrier problem is readily 
estimated. It is therefore the duty of every physician not to discharge 
a typhoid patient until he is certain that the patient no longer harbors 
any typhoid bacteria in the excretions. It is with this object in mind 
that the study of duodenal cultures was undertaken. 

Origin of the Epidemic. 

During the recent war, the internment camp for German civilian 
prisoners was situated at Hot Springs, N. C, on the west bank of the 
French Broad River, about 38 miles from Asheville. The internment 
camp was divided into two areas known as Camp A and Camp B. 
The water supply proved to be inadequate for both camps so that 
a separate supply was developed for Camp B by digging a number 
of shallow wells along the river bank. When these wells also proved 
inadequate, direct connection was made with the river water (French 
Broad) and this water was intended for flushing latrines. River water 
was usually applied once or twice a day. When river water was 
pumped, chlorination was applied. Instructions were in force not to 
drink the river water. Examinations of the original well water 
showed it to be perfect. The water from the French Broad River, 
however, is polluted and always carries a great deal of suspended 
matter. The first case of typhoid fever occurred at Camp B 
about July 20, 1918. On Aug. 5 there were about 50 cases 
with several suspects. On Aug. 12, 13, and 25 all cases of typhoid 
and typhoid suspects, a total of 183, were transferred to U. S. A. 
General Hospital No. 12, at Biltmore, N. C, where the writer 
was stationed. All these cases came from Camp B, apparently due to 






A. L. GAKBAT 5 

the polluted French Broad River water. Of these 183 cases, there were 
16 deaths; only 5 cases were definitely proved not to be typhoid fever. 

The study of these cases 1 did not terminate as is usual with the 
cessation of the acute manifestations. While abundant reports are 
found in the literature referring to symptoms and laboratory findings 
during the active stage of typhoid fever, comparatively meager and 
inaccurate statistics exist pertaining to convalescent typhoid patients. 
Hardly any large epidemics have been studied in detail, as the work 
entailed in the care of very many, for example 200, patients under one 
roof at the same time, has in the past made detailed research studies 
almost impossible. Conclusions were therefore formerly drawn from 
collected series of cases. This must lead to somewhat erroneous 
statistics, as the findings are obtained by different workers, at different 
times, and with different techniques. It is therefore felt that the 
report to be given here merits consideration, since all the results were 
obtained by the same worker under the same circumstances. Through 
the cooperation of Colonel F. F. Russell the writer was given all the 
necessary laboratory assistance. 

As there are several questions which will be constantly referred to 
throughout this monograph, it is wise to discuss them here, in order 
to avoid repetition in the various chapters. 

Medium Used for Typhoid-Colon Differentiation. 

The Endo medium was chosen for all the differential work, as we 
found it very accurate and very simple to make up. In its preparation, 
several details were considered absolutely essential for its proper 
action. Sterile stock 3 per cent agar (made in the usual way from 
chopped beef) was kept on hand in quarter liter and liter flasks. The 
required quantity for the day's work was titrated just before use and 
the reaction adjusted to 0.2 per cent acid to phenolphthalein. While 
hot, the agar was treated with chemically pure lactose, 10 gm. per liter. 
The powdered lactose itself was added, or this quantity was preserved 
in a solution of sterile water in individual tubes and thus used. Next 
1.8 cc. of fuchsin solution per liter were added to the hot agar. A 

1 A clinical study will be published by the writer in conjunction with Dr. E. 
Henes. 



6 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

filtered saturated solution of basic fuchsin in 95 per cent alcohol was 
employed. The agar became deep red. As the last step, the sodium 
sulfite solution was gradually added until the hot agar was entirely 
decolorized. It usually required about 25 cc. to the liter. A 10 per 
cent solution of pure dry sodium sulfite crystals in sterile water was 
made up fresh every day. Since various fuchsin solutions and also 
various preparations of sodium sulfite may differ, the absolute quanti- 
ties given above may not exactly hit the proper balance in separate 
lots. These were approximate, however, and the proper balance can 
easily be obtained by a little preliminary testing in which the sodium 
sulfite solution is added to definite quantities of the fuchsin-colored 
agar in a test-tube. The finished product was poured into large 
sterile Petri dishes. The covers were left off until the agar was hard. 
While hot, a pale rose color was present in the medium which faded to 
a very faint pink or became almost colorless on cooling. Under no 
circumstances were the plates exposed to sunlight or daylight, as this 
colored the medium red. The Petri dishes were covered with a dark 
towel or kept in the ice box until used. If all these details are strictly 
observed, the author feels that Endo's medium will be found to give 
as reliable results as those obtained by the other differential media 
proposed. (Krystallviolett of von Drigalski and Conradi, malachite 
green of Loeffler, brilliant green of Krumwiede.) 

Recognition of Typhoid Bacilli. — After incubation for 18 to 24 hours 
the typhoid colonies stood out on the plates as the smaller colorless 
colonies amidst the deeply fuchsin-stained colon colonies. The 
suspicious (typhoid) colonies were transplanted upon Russell's double 
sugar agar slants and further identified by specific serum agglutination 
tests. In several instances even then the result was doubtful, so that 
recourse was taken to injection of the doubtful organisms into rabbits 
and to examination of the obtained specific sera for agglutinins against 
known typhoid strains. 

Division of Typhoid Illness into Two Stages, 

For the elucidation of certain statistics, the author divided the 
typhoid illness into two stages: the acute stage and the stage of con- 
valescence. The first day when the temperature reached normal and 
remained normal was taken as the dividing point between these two 



A. L. GARBAT 7 

periods. The writer has always considered this a much more logical 
plan than the usual method of dividing the typhoid illness into 4 
weeks. Those who have seen a great deal of typhoid fever realize how 
almost impossible it is to tell during the course of the disease what week 
of the illness the patient is in at a particular time. It seems much more 
rational to wait until the fever has subsided and then use the first day 
of normal temperature as the landmark. If it is desired to know at 
what stage of the disease a certain phenomenon occurred, it can very 
readily be told by calculating backward from the date of normal tempera- 
ture and be designated in terms of days or weeks either before normal 
temperature or after the patient went to bed with fever. Similarly in 
the study of typhoid convalescence, it is more practical to state that a 
certain test was positive or negative 10 or 15 days after "normal tem- 
perature'' than to use the designation in terms of "day of disease," as 
"the 28th day of the disease." "Convalescence" is no longer " dis- 
ease" nor "illness." The course of typhoid fever is such a variable 
one that simply stating the "28th day of the disease," for example, 
associates with it no fixed idea of symptoms. In one patient, this day 
may coincide with the height of the fever stage, while in another it may 
coincide with subnormal temperature. 

The "duration of the disease" was estimated as the interval between 
the first and last days of fever. Usually, clinicians include in the 
"length of the illness" the time of incubation, but this period also is 
such a varying one that it seems wiser to go by the much more definite 
symptom of "fever" rather than the usual general guides of malaise or 
indisposition. The latter may be present a long time before the onset 
of typhoid fever and still not be dependent upon the infection. 



II. DUODENAL CULTURES VERSUS FECES CULTURES AS A MEANS OF 

DETECTING CARRIERS. 

History of the " Typhoid Carrier Problem. " 

The part played by human carriers in the spread of typhoid fever 
is a problem the solution of which was directly evolved from the views 
set forth by Robert Koch in his famous address of November, 1902, 
"Die Bekampfung des Typhus" (5). Even at that time, he con- 
sidered the typhoid patient or convalescent as the most fruitful 
source of further infection. This view was soon abundantly con- 
firmed by Frosch in 1903 (6), who had assumed the directorship of an 
experimental typhoid station at Trier, also by von Drigalski (7) at 
Saarbrucken, and Donitz (8) in Berlin. To Frosch belongs the credit 
for suggesting the hypothesis that the typhoid bacillus may lead a 
saprophytic existence in the intestinal tract, and it was von Drigalski 
who established on a bacteriological basis the hypothesis put forward 
by Frosch. Von Drigalski also recorded the first chronic carrier 
traced from convalescence onwards. In addition, he discovered the 
first female chronic carrier who gave no history of having passed 
through an attack of typhoid fever. With the recognition of the 
carrier state as a definite entity, various statistics appeared proving 
the validity of Koch's original dictum, and some authors have claimed 
that as high as 44 per cent of typhoid cases could be traced to typhoid 
carriers (4). It became of great importance to be able to detect 
the carrier by means of proper urine and stool examinations. For 
this purpose all types of special nutritive media were introduced, 
but, as will be seen presently, radical improvements upon these 
methods were necessary in order to obtain accurate results. 

In an article published by the author in 1916 (9) entitled, "Duo- 
denal Cultures in Typhoid Fever as a Means of Determining Com- 
plete Convalescence," 12 cases of typhoid fever were studied, in 
which comparative examinations made from the duodenal contents 
(bile) and the feces, demonstrated in 2 cases typhoid bacteria in 
the bile and not in the feces. In the present publication, the study 
of the bile as the source of typhoid bacteria in the stools of typhoid 

8 



A. L. GARB AT 9 

convalescents was resumed on a much larger and more detailed scale 
and the solution of a number of problems dealing with typhoid car- 
riers has been attempted. This paper deals with duodenal (bile) 
cultures made on 136 cases of typhoid fever. 

Technique for Obtaining Bile. 

The Einhorn duodenal tube was sterilized by boiling and given to the patient 
in the evening at 9 or 10, about 3 hours after the last meal. Various other 
times of the morning and afternoon were tried, but were given up, because the 
patient would thus miss a meal, and this often met with great objection. Only 
in rare instances was there any difficulty in having the patient swallow the tube 
because of gagging. Usually the tube would go down easily and by the following 
morning it had passed into the duodenum and bile could be aspirated with a 
sterile 10 or 20 cc. Luer syringe. It was necessary for the piston of the syringe 
to be a well fitted one, because at times suction had to be quite strong. The 
bile was collected in four or five separate sterile test-tubes; the first specimen 
usually contained mucus or other secretions that had collected in the tube during 
the night. This technique was found to be perfectly satisfactory and is some- 
what simpler than the one described by the author in 1916. In about 5 per cent 
of the cases, the tube remained in the stomach. This was probably due to gas- 
tric atony and the tests had to be repeated. 

When there was difficulty in obtaining sufficient bile, it was found that if the 
patient sat up in bed and bent his head forward between his knees, at the same 
time pressing upward on his abdomen with the palms of his hands, a flow of bile 
would set in. Or, if the patient was given a cold drink, the bile would appear, 
probably due to the reflex relaxation of the sphincter around the opening of the 
common bile duct. OccasionaUy, part of the fluid which the patient had drunk 
would be expelled through the pylorus into the duodenum so rapidly that on 
aspiration bile mixed with the fluid swallowed would be obtained. Thus, it is 
wise to give the patient sterile water to drink when this means of stimula- 
tion is employed. If secretion is obtained and one is doubtful whether it is bile 
or not, one can, at the bedside, give the patient some colored liquid to drink, 
grapejuice for example, and immediately thereafter aspirate. If the tube is in 
the stomach, the undiluted red-stained fluid is obtained on aspiration. In rare 
instances, if none of these methods yielded any bile, the author would inject 
5 or 10 cc. of sterile fluid through the tube and immediately thereafter aspirate 
again. This fluid would return bile-stained from its contact with the duodenal 
wall. In the vast majority of instances, none of these extra manipulations were 
necessary, and sufficient bile was obtained without any trouble if only patience 
was practiced. 



10 



TYPHOID CARRIERS AND TYPHOID IMMUNITY 



Characteristics of Bile Specimens. 

(a) Quantity. — It was surprising to note the large quantities of bile that could 
be aspirated at the first examination. In only 16 cases was less than 10 cc. 
obtained. The small quantity does not, however, interfere with the finding of the 
typhoid bacilli, because a positive duodenal culture is recorded in one patient 
from whom only 2 cc. of bile and in another from whom only 6 cc. had been 
collected. In Table I the cases are tabulated according to the various quantities 
obtained. 

TABLE I. 



No. of cases. 


Per cent of cases. 


Quantity of bile obtained. 






cc. 


16 


14 


Less than 10. 


43 


39 


10-20 


19 


17 


21-30 


21 


19 


31-40 


7 


6 


41-50 


2 


1 


51-60 


1 


1 


62 


1 


1 


80 


26* 







* Not estimated. 



{b) The consistency varied from thin, almost watery secretions, to thick mu- 
cous fluids which came through the tube with difficulty. The former were 
usually absolutely clear, while the latter were turbid or entirely opaque with a 
varying amount of a dirty granular sediment. 

(c) A variety of colors was noted; very light yellow, canary yellow, golden 
yellow, light green, dark green, light brown, dark brown, etc. 

(d) On microscopical examination, the clear fluids showed only a moderate 
number of bacteria, or none at all. The clear fluids were usually sterile. The 
turbid fluids contained a great deal of mucus mixed with a moderate or great 
number of leucocytes and numerous bacteria, usually bacilli. Frequently myelin 
drops were noted. A Gram stain showed mostly Gram-negative bacilli mixed 
with some Gram-positive cocci. 

No absolutely characteristic picture can be ascribed to those bile specimens 
which contained typhoid bacteria. While almost all of these fluids were thick, 
very turbid, and contained a good deal of mucus, the same findings were also 
present in those specimens which on culture showed colon bacilli. As a rule, 
however, the latter contained very many more leucocytes. In only one instance 
out of this entire series were actively motile typhoid bacilli (as proven later by 
culture) noted in hanging drops of the fresh bile specimens. 



A. L. GARB AT 11 

Technique for Bacteriologic Examination. 

Endo's medium was selected for typhoid-colon differentiation as it was found 
least complicated and very satisfactory. The details for its preparation are 
given under the general discussion. 

(a) The bile collected in each test-tube was examined separately. A broth 
culture and an Endo plate from each were prepared, thus making 4 broth tubes 
and 4 Endo plates from each patient. About lto 2 cc. of bile were added to the 
broth tube, and about 0.25 to 0.5 cc. was spread over a large Endo plate. No 
special dilutions were found more advantageous than others. The broth tube 
was plated after 24 hours incubation. At the Walter Reed Hospital where 
duodenal cultures were undertaken, the original bile was first incubated for 
24 hours and then plated. 

(b) The stool examination was made by the usual technique; namely, a piece 
of feces, about the size of a split pea, was rubbed up in about 10 cc. of broth, 
allowed to stand for about 15 minutes until the heavy parts had settled, and 
then a large loopful from the upper layer of the fluid was spread carefully over 
the entire surface of a hardened plate of Endo's medium. In the routine stool 
examination, two such plates were made from each specimen of feces. 

The problems which this study attempted to solve are so varied that possibly 
the best way of expressing the results is by stating the particular question under 
investigation followed by the answer as interpreted from the findings. 

Is the Repeated Examination of the Feces a Fair Index as to the Absence 
or Presence of Typhoid Bacilli in the Intestines? 

Almost all clinicians and bacteriologists agree that when a stool is 
reported as "no typhoid bacilli found, " this statement in many 
instances may mean nothing more than that the laboratory methods 
were such that the typhoid bacilli were not detected. As evidence 
that bacteriologic examination of the stool for typhoid bacteria is 
attended with uncertain results, one has but to note the different 
methods and the new media constantly devised for such examination, 
in the hope of improving the results. 

In our series of cases, we adhered strictly to the army rule of not 
considering a patient free of typhoid fever until 3 consecutive stools 
and urines examined at intervals of 6 days proved to be negative. 
The first specimens were sent to the laboratory when the patient's 
temperature was nearing normal, or had become normal. 

In 136 patients, bile cultures were made after 3 consecutive stool 
examinations had been found negative; i.e., apparently free of typhoid 



12 



TYPHOID CARRIERS AND TYPHOID IMMUNITY 



bacteria. Out of these 136, 20, or 15 per cent, still showed typhoid 
in the bile. Of these 20, 15 had never shown typhoid colonies in the 
feces, while in 5, typhoid bacteria had been demonstrated in the stool 
cultures at some time previously but had apparently cleared up so far 
as could be judged by the 3 consecutive negative feces cultures. 
Even more striking is the fact that 15 of these 20 patients, or 11 per 
cent of the cases examined, had not only 3 negative stools, but also 3 
negative urines to their credit when the positive growth in the bile 
was obtained. In other words, 11 per cent of the typhoid patients 
who are usually considered ready to leave the hospital and mingle with 
the community at large, may still be discharging typhoid bacilli unde- 
tected by the general method of stool examination. 



TABLE II. 



Name. 



Poelman. . . 
Bergenthal. 



Dura- 
tion of 
original 
infec- 
tion. 



days 
49 
44 



1st day 

of 
constant 
normal 
tempera- 
ture. 



Sept. 21 
" 23 



Date of 

3rd 
negative 
urine and 

stool 
cultures. 



Oct. 14 
Sept. 30 



Date of 
positive 
duodenal 
culture. 



Oct. 14 
" 3 



Date of 
onset 

of 
relapse. 



Oct. 16 
" 5 



Date of 
positive 

blood 
culture 

during 
relapse. 



Oct. 22 
" 8 



Date of 
normal 
tempera- 
ture after 
relapse. 



Nov. 5 
Oct. 31 



Date of 
negative 
duodenal 
culture 
after 
relapse. 



Nov, 8 
Jan. 6 



The remaining 4 per cent of the cases (5 patients) with positive bile 
cultures and negative feces cultures had other evidences of the per- 
sistence of typhoid besides the positive duodenal culture. Two still 
showed typhoid bacteria in the urine. Another had recurrent rises 
in temperature with tenderness over the gall bladder but a negative 
blood culture, probably recurrent attacks of cholecystitis. The 
other two developed definite relapses with positive blood cultures, 
after normal temperature for 25 days and 12 days respectively. In 
spite of 3 negative urines and stools these 2 patients began to run 
temperatures several days following the time of the positive bile 
culture (Table II). 

It is interesting to consider the hypothesis that some typhoid re- 
lapses may be due to the persistence of bacteria in the gall bladder as 
the source of a vicious circle. There is, first, the primary bacteremia; 
next, the settling of the bacteria in the gall bladder; then a reabsorp- 
tion of the bacteria either from the gall bladder or from the intestines, 



A. L. GARBAT 



13 



giving a renewed bacteremia and relapse in those patients in whom 
a sufficient degree of immunity has not taken place from the original 
infection. Thus a positive duodenal culture during the early convales- 
cence may be compared to a strongly positive Wassermann test in a 
lues asymptomatica — a danger sign of possible trouble. All relapses 
cannot, however, be explained thus, because there were instances 
where relapses occurred after a negative bile culture. Further in- 
vestigation along this line is necessary. 

The bile cultures were not always made on the same day as the 
third negative feces. The different periods of time which elapsed 
between the last negative feces and the positive duodenal culture are 
shown in Table III. 

table ni. 



No. of cases. 


Interval between last 

negative feces and 
positive bile cultures. 


No. of cases. 


Interval between last 

negative feces and 
positive bile cultures. 




days 




days 


5 





3 


7 


1 


1 


1 


9 


2 


2 


1 


11 


5 


3 


1 


12 


i 


6 







From this table it has been estimated that had bile cultures not been 
made and were the patients not required to observe the usual typhoid 
precautions after they had 3 negative urines and 3 negative stools, 
15 patients would have been excreting typhoid bacteria in their feces 
over a total period of 68 days. These figures are comparatively 
mild when one considers the length of time that these bile cultures 
continued positive after the third negative stool. 

The Army rule of keeping a patient at the hospital until 3 consecu- 
tive negative urines and stools at intervals of 6 days are reported, is a 
comparatively strict precaution. Many health boards and hospitals 
in this country do not adhere to such a wise requirement. A few years 
ago, systematic inquiries disclosed that out of 23 leading hospitals in 
this country, only 9 required an examination of both the urine and 
stools of their typhoid patients before discharging them from the hos- 
pital. One institution examined these excretions only when the pa- 
tient's occupation brought him into contact with foods. Another exam- 



14 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

ined the urine and not the feces; one even discharged patients with 
bacteria in the urine if these persistently remained there. 11 institu- 
tions disregarded such examinations altogether; 5 of these definitely 
stated that the technical phase associated with the inaccuracies of the 
findings in stool examinations did not warrant the time spent. The 
author has often felt the same way about the results of stool examina- 
tions and it is that sense of inaccuracy which led to the study of bile 
cultures. It is very discouraging to note that the 1920 New York 
City sanitary code regulations require that, in typhoid fever, quarantine 
should be continued until 10 days after the patient's temperature 
reaches normal and further until 2 specimens of feces collected at an 
interval of at least 24 hours are found to be free of typhoid bacilli (10). 
Let us hope that such a dangerous state of affairs, as evidenced by the 
cited statistics, will be remedied. 

Is It Possible that Typhoid Bacilli Are Destroyed on Their Way Down 

from the Gall Bladder, Thus Actually Giving a Negative 

Stool and a Positive Bile Culture? 

This question was answered in 9 cases. In 2, after an interval of 
6 days, the fourth specimen of feces came to the laboratory as part 
of the regular routine. Typhoid colonies were found. No special 
dilutions of the feces nor an increased number of Endo plates were 
necessary for their discovery. In 4 other patients with positive 
duodenal cultures, subsequent stools were especially reexamined, 
and, when 10 to 15 Endo plates from various dilutions of the feces 
were made, typhoid bacilli were recovered. 

Furthermore, it was found that in some of these patients with 
positive duodenal cultures and negative stools, the longer the typhoid 
bacteria persisted in the bile, the more likely was one to detect the 
typhoid colonies in the stools. Thus in 3 patients in whom the 
typhoid bacilli persisted in the bile for over 3 months after normal 
temperature, isolated typhoid colonies could be detected in the stool 
plates with little trouble at the end of this time; whereas, in the early 
days of convalescence, typhoid colonies were either not detected at 
all in the regular routine stool examinations or only after repeated 
and numerous cultures. At the same time, we meet with the diffi- 
culties of stool examinations even in chronic carriers. In one instance 



A. L. GARBAT 15 

of a permanent typhoid carrier, a heavy growth of pure typhoid bac- 
teria was isolated from the duodenum on two successive occasions. 
During the same time it required 60 Endo plates (10 made on each of 
6 successive days) to demonstrate the typhoid bacilli in the feces. 
The first 4 days (40 Endo plates) revealed no typhoid bacteria. On 
the 5 th day 4 out of the 10 plates showed 3 or 4 typhoid colonies 
per plate. The 6th day revealed no typhoid bacteria. While 
it is shown that there is a great discrepancy between the findings of 
duodenal cultures and feces cultures, the typhoid bacilli are not de- 
stroyed in the intestines but they are either absent in the particular 
drop or drops of feces that are examined or through the use of the usual 
technique they are overgrown by the colon bacillus. In the bile, the 
typhoid bacilli are more concentrated. Most authorities have been 
of this opinion, although definite proof in vivo was evidenced only by 
this method of duodenal cultures. At post-mortem, von Drigalski 
(11) and Jurgens (12) showed by cultural methods that in the intestinal 
tract from the duodenum down to the rectum, the number of typhoid 
bacilli decrease. In the duodenum and the upper portion of the 
jejunum one frequently meets with enormous numbers of typhoid 
bacilli in nearly or actually pure culture. 

On What Day of the Disease May One Expect the Duodenal Cultures to 

Become Negative? 

As was said in the general discussion, it is wise to designate 
the first day of normal temperature as the dividing point between 
acute disease and convalescence, so that it is more accurate to 
put the question: How soon after normal temperature may one 
expect the bile cultures to be negative? In order to have deduced 
any such fixed periods of time, it would have been necessary to 
do repeated cultures from the bile on the same patients at different 
intervals, beginning before the temperatures had reached normal. 
Since the main object of the present study was a determination of the 
comparative value of duodenal (bile) and stool cultures, the above 
plan was not adopted. The duodenal cultures were done at various 
intervals after the onset of normal temperature and it can be said 
that no definite conclusion was reached as to when the bile becomes free 
of typhoid bacteria. Table IV gives the number of cases and the 



16 



TYPHOID CARRIERS AND TYPHOID IMMUNITY 



time at which the duodenal examinations proved negative for typhoid 
bacilli. 

About 40 per cent of typhoid cases had negative duodenal cultures 
within the first month after the temperature reached normal. Had it 
been possible to take bile cultures on the other patients at a date 
previous to the times stated above, this percentage would undoubtedly 
have been higher. In some cases, duodenal examinations were made 
even before the temperatures had become normal, and in others after 
only 1 or 2 negative urines and stools; and at these times, the bile was 
already free of typhoid bacteria in some instances. It can, therefore, 
be stated that the period of time after normal temperature when the 
bile becomes free of bacteria is a varied one. Patients may be dis- 

TABLE IV. 



No. of cases. 


Per cent of cases. 


Interval after normal temperature 

when duodenal 

culture was negative. 






days 


7 


6 


10 


13 


11 


11-20 


34 


22 


21-30 


42 


37 


31-40 


17 


13 


41-50 


2 




51-60 


1 




61-70 



charged before 3 stools have been examined and found negative as 
long as the duodenal cultures show no typhoid bacilli. Such direct 
examination is much more accurate than stool examinations. 

It is much more important to analyze the time relationship of the 
positive duodenal cultures. Only 20 of our cases (15 per cent) showed 
positive bile cultures during convalescence, but it must be remembered 
that bile cultures were only started after 3 stools from a given patient 
had already been examined at intervals of 6 days and reported as 
negative. Had duodenal cultures been instituted at an earlier date, 
it is more than probable that a greater number of positive cultures 
would have been obtained. The presence of typhoid bacteria in the 
bile during the acute stage of typhoid fever is a different problem. 
Table V shows the number of days between the onset of normal 



A. L. GARB AT 



17 



temperature and the first positive bile culture. Here we see that in 
10 cases (7.5 per cent) the duodenal cultures were positive later than 
1 month after the beginning of normal temperature. 



table v. 



No. of cases. 


Interval after norma] 
temperature when duo- 
denal culture was positive. 


No. of cases. 


Interval after normal 
temperature when duo- 
denal culture was positive. 




days 




days 


4 


1-10 


8 


31-40 


3 


11-20 


1 


51-60 


3 


21-30 


1 


61-70 



How Long Did These Patients Continue to Harbor Typhoid Bacteria 

in the Bile? 

4 cases, or 3 per cent of the typhoid patients, showed typhoid 
bacilli in the bile 4 months after the fever had ceased (Table VI). 
It is interesting to refer to the findings in the stool cultures of these 
carriers at the same date (Table VII). It is noted that even 
in pronounced carriers duodenal cultures are much more reliable 
than stool cultures. Naturally, once it is ascertained or even 
suspected that a particular convalescent typhoid patient is excret- 
ing typhoid bacilli in the feces, continued patience with the 
stool examinations expressed by large numbers of cultures may 



TABLE VI. 



Name. 



Ericksen. . 
Schaefer.., 
Hoffman. . 
Mueller, E 

Ziska , 

Gutte 

Lehman.. , 



1st duodenal 
culture. 



Interval 

after 
normal 
temper- 
ature. 

days 

29 
11 
30 
14 
9 
62 



Result. 



+ 
+ 

+ 
+ 
+ 
+ 



2nd duodenal 
culture. 



Interval 

after 
normal 
temper- 
ature. 

days 

63 
39 
50 

55 

42 

74 

108 



Result. 



+ 
+ 
+ 
+ 
+ 

+ 



3rd duodenal 
culture. 



Interval 

after 
normal 
temper- 
ature. 

days 

97 
69 
81 
82 
72 
90 
111 



Result. 



+ 
+ 
+ 



4 th duodenal 
culture. 



Interval 
after 
normal 
temper- 
ature. 

days 

128 
106 
122 
111 
109 
127 
143 



Result. 



+ 

+ 



+ 



18 



TYPHOID CARRIERS AND TYPHOID IMMUNITY 



demonstrate the bacteria. However, one has no guide as to 
those who are more likely to become typhoid carriers. And since 
it is impracticable to undertake a long special feces investigation 
on every patient, particularly when one is dealing with a typhoid 
epidemic, main reliance should be placed upon bile cultures; for, as 
has been seen, the usual routine stool examinations during con- 
valescence missed 15 per cent of carriers, and of these, 3 per cent 
were carriers for over 4 months, possibly permanent carriers. 



TABLE VII. 





Ericksen. 


Schaefer. 


Hoffman. 


Lehman. 




No. of Endo 












plates made 


8 


8 


6 


60 




from feces. 












No. of plates 










Feces. * 


showing ty- 


8 





4 


4 


phoid colonies. 












Proportion of ty- 












phoid to colon 


lto75 




1 to 50 


lto50 




colonies on 


or 100 





or 75 


or 75 




b these plates. 












No. of typhoid 


340 to 450 


5 to 10 


350 to 500 


40 to 50 




colonies on En- 


colonies in 


colonies in 


colonies in 


colonies on 


Bile. 


do plates from 


pure culture 


pure culture 


pure culture 


each plate. 




bile of same 


on each 


on each 


on each 






date. 


plate. 


plate. 


plate. 





How Numerous May the Typhoid Bacteria Be in the Bile? 

In general, if the typhoid bacteria are present in the bile in great 
numbers, many typhoid colonies are seen on the original Endo plate 
made directly from several drops of the bile. On the other hand, if 
the number is not so great, the growth is obtained principally in the 
broth and only very few colonies or none at all are noted on the 
original Endo plate. Thus, 2 patients who showed a heavy growth 
on the original Endo plate at the first culture showed a growth only 
in the broth and not on the Endo plate at the reexamination of 
the bile 1 month later. Further examination after several weeks' 
interval, gave no typhoid bacilli even in the broth culture. In 3 



A. L. GARBAT 19 

other patients the growth was just as heavy at the second and third 
examinations as at the primary culture. It was difficult to get 
accurate figures concerning the actual number of colonies in the 
bile because pour plates fromEndo's medium do not distinctly differ- 
entiate typhoid from other types of organisms. Approximate esti- 
mations were made by spreading 0.5 cc. of the bile very carefully 
over the entire surface of an Endo plate. In many instances the 
colonies were in such great numbers that they were confluent and 
difficult to count. As many as 32,000 colonies per cc. have been 
estimated by this method and this in a man (Ziska) in whom the 
stool culture was negative. It must be remembered that this 
number of colonies would represent a far greater number of bacteria. 

In the Cases with Positive Duodenal Cultures Are Typhoid Bacilli 

Constantly Present in the Bile or Is the Excretion 

an Intermittent One? 

A positive solution to this question is important in order: (1) to 
establish whether there was any best time for culturing the bile; (2) to 
explain the apparent irregularity in the excretion of the typhoid 
bacilli in the feces ; (3) to ascertain whether 1 negative duodenal cul- 
ture was sufficient to exclude the existence of a carrier condition. 

1. The question of hourly intermittency was studied. Two carriers 
(for a pecuniary consideration) retained the duodenal tube for 24 
hours without taking food, and specimens of pure bile were examined 
every 2 hours. After each sample was collected, sterile distilled water 
was forced through the tube in order to prevent the bile from stag- 
nating and mixing with the next specimen. It was found that typhoid 
bacilli were constantly present, as is noted in Table VIII. 

2 and 3. When duodenal cultures were repeated in carriers at 
various intervals over a longer period of time, it was found that as a 
general rule cultures would either consistently continue positive, or if 
they once became negative they would remain so. This is very 
different from the feces findings in these carriers. Bacteria are often 
reported to be absent from the feces for months, only to recur again 
later on. It seems to be almost definitely established in the literature 
that the excretion of typhoid bacilli in the feces is intermittent. 



20 



TYPHOID CARRIERS AND TYPHOID IMMUNITY 



TABLE VHI. 





Bile obtained. 


T y.% 


Name. 


Time. 


Quan- 
tity. 


Transparency. 


Color. 


phoid 
present. 




a.m. 

9.00 
11.00 

p.m. 

2.00 
4.00 
6.30 
9.00 

a.m. 

9.30 
11.30 

p.m. 

2.00 
4.00 
6.30 
9.00 


cc. 

4 

12 

13 

16 

21 

6 

3 
10 

9 
15 

8 
22 


Turbid. 
Clear. 

u 

Slightly turbid. 

Clear. 
tt 

« 

Slightly turbid. 

Clear. 
tt 

u 


Yellow-green. 
tt tt 

tt it 
tt tt 
tt tt 
tt tt 

tt tt 
tt tt 

Orange. 

Yellow-green. 
u tt 

Orange-yellow. 


+ 




+ 

+ + 
+ + 
+ + 

+ 




+ 

+ 
+ 
+ 
+ 



Semple and Greig (13), who published a thorough bacteriological 
investigation of typhoid convalescents, show that carriers may be 
readily overlooked if the routine feces examination is limited to 3 
or 4 cultures during the 6 weeks following defervescence. Klinger 
(14) published most interesting results in this respect. 





Stool 




Stool 




Stool 




Stool 




Stool 


Date. 


cul- 


Date. 


cul- 


Date. 


cul- 


Date. 


cul- 


Date. 


cul- 




ture. 




ture. 




ture. 




ture. 




tuie. 


1904 


1904 


1904 


1904 


1905 




Jan. 30 


— 


May 3 


— 


Aug. 10 


— 


Oct. 11 


+ 


Feb. 13 


— 


Feb. 10 


+ 


" 10 


— 


" 16 


— 


" 29 


— 


" 18 


+ 


" 11 


+ 


" 19 


+ 


Sept. 12 


+ 


Nov. 2 


+ 


Mar. 24 


+ 


Mar. 26 


— 


June 8 


+ 


Oct. 1 


— 


" 24 


+ 


Apr. 26 


+ 


Apr. 3 


+ 


July 2 


+ 


" 5 


— 


Dec. 22 


+ 


May 12 


+ 



+ indicates typhoid bacilli present; — , typhoid bacilli absent. 



The writer is convinced that this intermittency is only apparent; 
were duodenal cultures made during those periods when the stool is 
apparently free from bacteria, typhoid bacilli would undoubtedly be 



A. L. GARB AT 21 

present in the bile. There are, however, exceptions to this uniformity 
of excretion in the bile. Occasionally a negative duodenal culture was 
interspersed among positive ones. This intermittency was rare and 
the negative findings would not persist for any length of time; often 
as early as the next day a positive culture would again be noted. No 
definite explanation can be offered for this variation. In two patients 
there was an associated cholelithiasis, so that possibly the stone ob- 
structed the cystic duct and the bile at the time of culture was ob- 
tained from a non-infected liver. That such conditions exist was 
proved by operation and by postmortem examination, and they are 
reported by the writer further on. In another case, an occasional 
negative culture amongst numerous positive ones was noted after a 
cholecystectomy failed to cure the carrier state. In these liver in- 
fections, intermittency can only arise if the particular negative 
specimen happens to be drained from a part of the liver which was not 
infected. Taking into consideration such occasional irregularities, 
the author requires two consecutive negative bile cultures made at 
intervals of one or more days instead of a single negative bile culture, 
before a patient is safely considered free of typhoid bacilli. This 
precaution applies especially to three groups of cases: (1) those 
who once showed a positive typhoid culture in the bile; (2) those 
in whom a surgical operation (cholecystotomy or cholecystectomy) 
had been performed for the cure of the carrier condition; (3) those 
who during the acute illness or convalescence manifested symptoms of 
cholecystitis or cholelithiasis. As will be seen later on, it is these 
patients who usually become carriers. 

Should Stool Examinations Be Entirely Discarded in Favor of Bile 

Cultures or Is There a Type of Pure Intestinal Typhoid Carrier 

Whose Bacteria Do Not Lodge in the Bile but 

in the Intestine and Are Therefore Detected 

Only by Stool Examinations? 

The existence of a pure intestinal carrier has been a disputed 
question but a very important one, especially from the standpoint 
of surgical therapy; for excision of the gall bladder in these cases will 
not effect a cure. Of our entire series of 164 typhoid cases studied, 
there was only one patient who from the very beginning of his con vales- 



22 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

cence, 5 days after normal temperature, began and continued to show 
typhoid bacteria in the stools in almost pure culture. In spite of 
this, 4 duodenal cultures were made during the first 2 months 
after normal temperature, and in none of them were typhoid bacilli 
isolated. The only bacteria found were colon bacilli. There was 
nothing unusual in this patient's clinical history. He was 54 years 
old, and reported sick Aug. 2, 1918, with the usual symptoms of head- 
ache, lassitude, and fever. He had one typhoid inoculation on July 
26, 1918. He ran a comparatively mild typhoid, with fever for 
approximately 3 weeks. There were no complications and he con- 
valesced without interruption. 

One cannot deny that types of pure intestinal carriers do exist, 
although they comprise only about 2 per cent (1 in 53) of all typhoid 
carriers, and only about 0.6 of 1 per cent of all typhoid patients. A 
detailed study of the different types of carriers is taken up in Section 
III, but it may be said here that an intestinal carrier is very readily 
differentiated from a bile carrier by stool examinations. In the 
former, there is no difficulty in detecting the typhoid bacteria. They 
begin to appear in the stools early during convalescence, and are 
found practically in every specimen in very great numbers and in 
almost pure culture. In the bile carriers, if typhoid colonies are 
found in the stool cultures at all, they appear there with great irregu- 
larity (in 1 out of 3 to 5 cultures) and in fewer numbers than in in- 
testinal carriers. For example, on the Endo plate made from the 
stool of a bile carrier, the ratio between the typhoid and the colon 
colonies would be approximately 1 to 25 or 75, while in the intestinal 
carrier this proportion would be reversed. In the latter, it seems 
as if the flora of the intestine are changed from colon to typhoid. 
A more detailed discussion of this topic is undertaken in Section III 
on Typhoid Carriers. 

What Other Types of Bacteria Were Found in the Duodenal Cultures, 
either Alone or in Association with the Typhoid Bacillus? 

Out of 39 duodenal cultures which showed typhoid bacteria, 32 
(82 per cent) were pure cultures, 4 (10 per cent) were mixed with 
colon bacilli, and 3 (8 per cent) with the Staphylococcus albus. The 
more persistent carriers had pure cultures. However, even in the 



A. L. GARBAT 



23 



mixed cultures the typhoid colonies stood out prominently on the 
Endo plates and were isolated with no difficulty. Table IX shows 
other bacilli found in 132 cultures which did not contain the typhoid 
bacillus. 

table rx. 



No. of cases. 


Per cent of cases. 


Bacteria found. 


42 


32 


Colon bacillus. 


13 


10 


Staphylococcus albus. 


5 


4 


" aureus. 


12 


10 


and colon bacillus. 


8 


6 


An intermediate 


2 


0.1 


Bacillus proteus. 


50 


38 


Sterile. 



The items of interest in the above figures are, first, the high per- 
centage of pure typhoid growths, and, secondly, the high percentage of 
sterile cultures. The last was especially surprising in view of many 
obstacles which were encountered and which interfered with the usual 
rules observed in taking sterile cultures. 



III. TYPHOID FECES CARRIERS, WITH SPECIAL REFERENCE TO A 

CLASSIFICATION OF THE VARIOUS TYPES AND THEIR 

SURGICAL TREATMENT. 

Temporary Versus Permanent Typhoid Carriers. 

Every typhoid patient who continues to show typhoid bacteria in 
the excreta (urine or feces) after the acute disease is over, should be 
classed as a " carrier. " This carrier state may ultimately cease, in 
which case the individual is considered a " temporary carrier, " or it 
may continue the rest of the patient's life and then the individual is 
classed as a "permanent carrier." Temporary carriers are usually 
such for only weeks or months and then clear up ; occasionally they 
persist for a year or even longer and then they are known as " chronic M 
carriers. It is safest, however, to consider every carrier a permanent 
one until he is proved otherwise. 

It is difficult to determine how long a time must elapse before a 
temporary carrier can be classed as a chronic or probably permanent 
one. It was found that those patients who showed typhoid bacteria 
in the stool for longer than 3 to 4 months after normal temperature, 
usually became chronic or permanent carriers. 

Diagnosis of Feces Carriers. 

We advise the use of the general term " feces carrier" to include all 
patients who show typhoid bacteria in the feces, rather than the 
term "intestinal carrier," because the latter designation should be 
reserved for a special class of feces carriers. 

The finding of typhoid bacilli directly in the bile has formed our basis 
for the designation of feces carriers. This method determines much 
more readily than stool cultures the probable presence of typhoid 
bacteria in the intestinal tract, especially during the early part of 
convalescence from typhoid fever. In our series of 136 cases, 13 
feces carriers would have escaped detection if duodenal cultures had 
not been made. Cultures of the stool alone may suffice for the 
detection of "chronic" or "permanent" feces carriers because in 

24 



A. L. GARBAT 25 

these the typhoid bacteria have reached to great numbers in the 
intestines. During the first weeks or months after normal tempera- 
ture, however, and this is just the important time for the detection 
of the carrier, it has been demonstrated that, while the bile may be 
full of typhoid bacteria, few or no typhoid colonies will be seen in the 
routine stool cultures of some patients. 

No feces carrier should be dismissed as having been only a tem- 
porary carrier until repeated duodenal cultures show no typhoid 
bacilli. It is fully realized that this method is more troublesome for 
the patient than stool cultures; on the other hand, it is much safer 
for the community. 

In the following study of 164 typhoid patients, at least 4 stool 
examinations by the Endo method were made on each patient. In 
addition, duodenal cultures were made on 136 of them. It is to be 
kept in mind that these tests were only started during convalescence, 
after the patient was free of fever and had remained so; in other 
words, at a time when the laity and some physicians have a tendency 
to leave off the usual precautions taken during the acute stage of 
the infection in order to prevent its spread. 

Frequency of Various Types. 

Of these 164 typhoid cases, 39, or 21 per cent, showed typhoid 
bacilli in the feces during convalescence. In addition, there were 14 
cases in whom 3 consecutive stool examinations proved negative, while 
duodenal cultures showed numerous typhoid bacteria. Thus, adding 
these together, we find that 53, or 32 per cent, continued as feces 
carriers after the temperature reached normal. 

This is a very high percentage in comparison to the figures reported 
by other writers. 

per cent 

Schroder (15) 7.9 

von Drigalski (11) 11.0 

Lentz (16) 4.0 

Klinger (17) 11.6 

Semple and Greig (13) 11.6 



26 



TYPHOID CARRIERS AND TYPHOED IMMUNITY 



The typhoid bacilli persisted in the stools of these patients for vary- 
ing lengths of time. Results in the 53 positive cases are shown in 
Table X. 



TABLE X. 



No. of cases. 


Per cent of all 


Per cent of all 


Duration of carrier state 


positive cases. 


typhoid cases. 


after normal temperature. 








weeks 


3 


5.5 


1.8 


1 


9 


17.0 


5.4 


2 


10 


19.0 


6.0 


3 


7 


13.0 


4.2 


4 


4 


7.0 


2.4 


5 


3 


5.5 


1.8 


7 


6 


11.0 


3.7 


8 


2 


3.7 


1.2 


9 


1 


2.0 


0.6 


10 


1 


2.0 


0.6 


11 


1 


2.0 


0.6 


12 


2 


3.7 


1.2 


17 


1 


2.0 


0.6 


18 


1 


2.0 


0.6 


19 


2 


3.7 


1.2 


21* 



Summary in terms of months. 



29 
13 

5 
6 



55.0 
24.0 
10.0 
11.0 



17.4 
7.9 
3.0 
3.6 



months 
1 

2 
3 

4* 



* And longer. 



At the time of writing, the typhoid bacilli had cleared up in all 
but 7 carriers who had been observed for 12, 17 (2 cases), 18, 19, and 
21 (2 cases) weeks respectively after normal temperature. 

Judging by the stool cultures, surely 4, if not all of them, will un- 
doubtedly remain chronic or permanent typhoid feces carriers; this 
makes 2.4 per cent to 4.2 per cent of all typhoid cases. These figures 
correspond with the findings of others. 



A. L. GARBAT 27 

per cent 

Hetsch (18) 4.62 

Fornet (19) 0.9 

Kayser (20) 5.0 

Park (21). 5.0 

Kirchner and co-workers (22) 5.0 

Frosch (23) 2.47 

Mayer (24) 4.0 

TYPES OF FECES CARRIERS. 

The gall bladder, or rather the bile coming from the gall bladder, 
has been conceded by all as the source of the typhoid bacteria in the 
feces. By means of duodenal cultures, a finer classification is possible. 
Feces carriers may primarily originate as one of three types: (a) 
intestinal carriers, (b) gall bladder (bile) carriers, (c) liver or duct 
(bile) carriers. 

Intestinal Carriers. 

An intestinal carrier is one in whom the typhoid bacteria in the 
feces come primarily from the intestines and not from an infected gall 
bladder or liver by means of the bile. The existence of a true in- 
testinal type of carrier has never been definitely accepted. It is even 
denied in the recent article of Nichols (41). A negative proof was 
presumably offered by those cases in the literature in whom chole- 
cystectomy with excision of the cystic duct, had failed to cure the carrier 
state. Such evidence in favor of the existence of intestinal carriers 
is insufficient, because, as will be seen further on, the typhoid bacteria 
in the feces of patients after cholecystectomy, may originate higher 
up than the gall bladder, in the liver or gall ducts. Positive evidence 
for the existence of a pure intestinal carrier type is afforded by means 
of duodenal cultures and was proved in only one case of our entire 
series. This was a patient 44 years old who reported sick Aug. 2, 
1918, with the usual symptoms of headache, lassitude, and fever. He 
had had an antityphoid inoculation 7 days previously. He ran a com- 
paratively mild typhoid fever for approximately 4 weeks. There were 
no complications and he reached normal temperature and convalesced 
without interruption. The first routine stool culture made 5 days 



28 



TYPHOID CARRIERS AND TYPHOID IMMUNITY 



after normal temperature revealed the great proportion of colonies on 
the Endo plate to be typhoid colonies. The subsequent specimens 
of feces continued to show almost a pure culture of typhoid bacteria. 
This has persisted up to the time of writing (Feb. 20, 1919), 21 weeks 
after normal temperature and will probably remain so. 2 During 
the first 2 months of convalescence, however, 4 duodenal cultures 
revealed no typhoid bacteria in the large quantities of pure bile 
obtained. Actual dates of examinations are shown in Table XL 



TABLE XI. 



Date of normal temperature. 


Dates of positive stool cultures. 


Dates of negative duodenal cultures. 


Aug. 28 


Sept. 2 
" 14 
" 23 

Oct. 10 
" 19 
" 26 

Nov. 16 


Sept. 25 

Oct. 15 

" 23 

« 29 



Thus it can be assumed that types of pure intestinal carriers exist. 
They comprise only about 0.6 per cent (1 out of 164) of all typhoid 
patients and 2 per cent (1 out of 53) of all feces carriers, temporary 
and permanent. Of the permanent feces carriers, 1 out of 5 or 6 may 
originally have been a pure intestinal carrier. The fact that there is a 
type of intestinal carrier is extremely important to know, for, as will 
be discussed more fully further on, cholecystectomy in this type of 
case is of no value. It is possible to differentiate with reasonable 
certainty an intestinal carrier from a bile carrier, by stool and duo- 
denal cultures, especially in the early period of the carrier state. The 
intestinal carrier begins to show the typhoid colonies in the feces 
plate cultures during early convalescence and they persist in almost 
every stool specimen in very great numbers and in almost pure 

2 This prediction came true. The patient was operated upon several months 
later. Cholecystectomy was performed, but the carrier condition has continued. 



A. L. GARBAT 



29 



TABLE XH. 



Name. 


Date of normal 
temperature. 


Dates of cultures. 


Feces cultures. 


Duodenal cultures. 


Ericksen 


Aug. 27 


Sept. 11 
" 20 








— 








" 26 


+ 


+ 






Oct. 3 


— 








" 11 


— 








" 18 


— 








" 29 




+ 






Dec. 2 




+ 


Schaefer 


Sept. 24 


Sept. 14 
" 21 








— 








" 28 


— 








Oct. 5 




+ 






" 8 


— 








Nov. 2 




+ 






Dec. 2 




+ 






" 31 


— 




Hoffman 


" 10 


Sept. 13 
" 24 


+ 














" 30 


— 








Oct. 4 


— 








" 11 




+ 






Nov. 1 




+ 






Dec. 2 




+ 






Jan. 2 




+ 






" 12 


— 








" 20 


— 




Lehman 


" 12 


Sept. 5 
" 11 










— . 








" 17 


— 








" 20 




4- 






" 21 


— 








" 23 


— 








" 30 


— 








Oct. 7 


— 








" 20 


— 








" 27 


— 








Jan. 6 




+ 






u 9 




+ 



+ indicates typhoid bacilli present; — , typhoid bacilli absent. 



30 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

culture. It seems as if the entire intestinal flora are changed from 
colon to typhoid. On the other hand, in those cases where the typhoid 
bacilli in the intestines originate in the bile, the typhoid colonies on 
plate cultures made from the stool during early convalescence are 
present either in very small numbers (1 typhoid colony to 50 or 
75 colon colonies) or are absent entirely. The diagnosis of the bile 
carrier state is possible only by duodenal culture and not by feces 
culture, as is seen in Table XII. The results in this table are in 
marked contrast to the findings in the intestinal carrier quoted 
previously (Table XI) . 

Bile Carriers. 

The bile may transport the typhoid bacilli into the intestines from 
either one or both of two sites: (a) the gall bladder, (b) the liver 
or bile ducts. 

An artificial experiment could not have been planned to differentiate between 
these two sources better than the solution of nature offered by two cases of the 
series. Two patients, Karpinsky and Lehman, manifested symptoms referable to 
the gall bladder during their convalescence. 

At this time, direct culture of the bile by means of the duodenal tube showed 
numerous typhoid bacilli in Lehman and none in Karpinsky. Cholecystectomy 
with complete excision of the cystic duct was done in both (Major Kammerer). 
A pure culture of typhoid bacteria was obtained from the contents of each gall 
bladder. The apparent discrepancy in the case of Karpinsky of the negative 
bile culture before operation and the positive culture from the gall bladder was 
explained at the time of operation. A large stone was fixed in the cystic duct 
which completely occluded this passageway. The gall bladder was contracted, 
had a very much hypertrophied wall and contained a small amount of thick, 
greenish mucous fluid. The bile we had cultured from the duodenum before 
operation had come directly from the liver which was not infected and did not 
enter the gall bladder which was the only seat of infection. The mucoid bilious 
fluid in the gall bladder escaped into the duodenum probably only at irregular 
intervals as was evident by 1 stool examination when few typhoid colonies were 
present. Far different, however, were the conditions in the other patient (Leh- 
man) in whom typhoid bacteria were found in the bile from the duodenum before 
cholecystectomy and also in the bile of the excised gall bladder. At operation 
there was discovered a large chronically inflamed gall bladder, abnormally thick- 
ened and with numerous stones but all free so that there was no interference with 
the lumen of the cystic duct. After complete healing of the abdominal wounds 
in both patients, duodenal cultures were repeated in each. In Karpinsky (where 
the bile coming from the liver was sterile) it was found that typhoid bacteria 



A. L. GARB AT 31 

remained absent, and the patient was cured. In Lehman, however, n spite 
of complete excision of the gall bladder and the cystic duct, repeated duodenal 
cultures were positive; probably, even before the operation, the bile which came 
from the liver and before it entered the gall bladder was already infected and 
remained infected after cholecystectomy. 

Detailed study shows that it is this condition of hepatic carrier 
rather than the condition of intestinal carrier which in most cases 
accounts for the persistence of the carrier state after removal of the 
gall bladder and cystic duct. That our patient Lehman was not an 
intestinal carrier can be readily noted by the results of the stool 
cultures. Seven routine stool examinations made at intervals of 5 to 7 
days from Sept. 5 to Oct. 18 (the date of operation) showed no typhoid 
colonies, although duodenal examinations on Sept. 20 showed a pure 
culture of very numerous typhoid bacilli. Again after operation, iso- 
lated specimens of stool showed no typhoid organisms while duodenal 
cultures repeatedly demonstrated a heavy growth of typhoid bacilli. 
A systematic search in the stool was then undertaken and out of 163 
Endo plates (embracing a period of 2 weeks) prepared from various 
dilutions of daily stool specimens, 1 1 plates were found which showed 
few scattered typhoid colonies. As was discussed above, such 
findings in the stool are characteristic of a gall bladder or liver carrier 
and not an intestinal carrier. Were this patient an intestinal carrier, 
there would have been no difficulty in detecting typhoid in the stool 
in great numbers both before and after operation, as was the case in 
our one example. A more detailed history of these two patients is 
here given for those who may be interested in any particular data. 

Case 1. — Alfred Karpinsky, Register No. 571, age 42 years; born in Germany; 
sailor 

Past History. — Nothing of importance is noted in his habits, family history, 
or venereal history. Has never been sick before. 

Present Illness. — Admitted to U. S. A. General Hospital No. 12 on Aug. 14, 
1918, having been sick with headache and fever for about 8 days before this date 
at Hot Springs, N. C. Had received one antityphoid inoculat : on there before 
admission to the hospital. 

Examination on Admission to U. S. A. General Hospital No. 12 by Lieutenant 
Sanders. The patient had no complaints. Roseola in great numbers over 
thorax, abdomen, back, and thighs. Lungs. — Occasional rales. Heart. — Slightly 
enlarged to left; blood pressure 100/70. Abdomen. — Not distended, not tender. 



32 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

Liver. — Edge felt 1 inch below costal margin. Spleen. — Edge palpable £ inch 
below costal margin. Temperature course. — Fluctuated from 102-103.6° reaching 
104°F. only once; temperature continued from Aug. 14, date of admission, 
to Aug. 27, when it reached normal and continued so (total fever course ap- 
proximately 21 days). 

Early Laboratory Examinations. — Blood culture. — Aug. 18, negative. Widal 
test. — Positive. Blood count. — White blood cells, 10,550: polymorphonuclears, 
58 per cent ; lymphocytes, 42 per cent. Urine. — Trace of albumin, few erythrocytes. 

Further Course of Disease. — (Complication.) Patient did not feel sick during 
fever course. On Sept. 1, 4 days after the beginning of normal temperature, 
patient complained of pain in abdomen and on examination there was obvious 
tenderness in right upper quadrant and muscular rigidity. The temperature 
suddenly rose to 105°F., but came down in 2 days. Blood count. — White blood 
cells, 11,800: polymorphonuclears, 55 per cent. Diagnosis. — Acute cholecystitis. 
The abdominal symptoms subsided entirely in 8 days and patient felt well again. 
On Oct. 8, 1918, about 1 month after the first attack, the patient again com- 
plained of pain in abdomen and again there was rigidity and tenderness over the 
gall bladder region. Blood count. — White blood cells, 11,750: polymorphonu- 
clears, 56 per cent; lymphocytes, 44 per cent. Duodenal culture. — No typhoid 
bacilli, few colon bacilli, and many leucocytes. This attack was not as severe 
as the first; the temperature only rose to 101°F. for several days. The patient 
consented to operation. 

Operation Report by Major Kammerer, Oct. 9, 1918. — Cholecystectomy. Many 
old adhesions about large gall bladder. Riedel's lobe present. Separation of 
gall bladder from bed of liver somewhat difficult. Gall bladder contained 21 
large and small calculi varying from \ to 1 inch in diameter, with 1 of the 
larger stones in the cystic duct. Wall of the gall bladder about \ inch thick; 
cystic duct ligated at junction with hepatic. Considerable hemorrhage from 
liver bed controlled by tampon. Cultures from gall bladder contents showed pure 
growth of Bacillus typhosus. 

Surgical Course after Operation. — About 1 week after the operation (Oct. 
16, 1918), the patient became jaundiced and there was a slight rise in temperature. 
There seemed to be an obstruction to the flow of bile because the stools became 
clay colored. The tampons were removed from the wound after which there 
was a profuse drainage of bile for about 3 weeks. Then the patient's jaundice 
disappeared; the stools resumed their normal color; the drainage ceased almost 
entirely; the wound began to close. It was healed entirely on Jan. 10, 1919. 

Results of stool, urine, and duodenal cultures are shown in Table XIII. 

Condition at Time of Writing {Feb. 20, 1919) .—Patient is feeling perfectly well; 
is up and about and is to be sent to Fort Oglethorpe. 

Case 2. — Herman Lehman, Register No. 505, age 34 years; born in Germany; 
barber. 

Past History.— Had volvulus at age of 15; otherwise nothing of importance 
is noted in personal or past history. 



A. L. GARBAT 



33 



Present Illness. — Began about July 27, 1918, with weakness, loss of appetite, 
and slight fever. 

Examination on Admission to U. S. A. General Hospital No. 12 by Lieutenant 
Sanders, Aug. 14, 1918. Patient complained of headache, abdominal pains, and 
deafness in left ear. General condition fair ; scattered roseola over body. Heart. — 
Action good; pulse slow; blood pressure 100/70. Abdomen. — Median scar from old 
volvulus operation; pain, tenderness, and rigidity in right upper quadrant. 
Spleen. — Just palpable. Diagnosis. — Acute cholecystitis complicating typhoid 
fever. Temperature course. — Patient came in with irregular temperature of 102- 
104°F., which gradually subsided in 1 week (Aug. 28, 1918). After several 
days of normal temperature, the fever slowly rose to 105°F. and then gradually 
came down again to normal (Aug. 25 to Sept. 14). 





TABLE 


XIII. 




Dates of cultures. 


Feces cultures. 


Urine cultures. 


Duodenal cultures. 


1918 








Sept. 1 


— 


+ 




" 10 


+ 


+ 




" 21 


— 


— 




" 27 


— 


— 




Oct. 3 


— 


— 




" 10 


♦ 




— 


" 24 


* 


* 




1919 








Jan. 1 




* 




" 2 


* 




* 


« 9 


* 




* 



* Subsequent to operation. 

Early Laboratory Examination. — Blood culture. — Aug. 18, negative; Aug. 30, 
positive. Widal test. — Positive. Blood count. — Aug. 14, white blood cells, 
4,850: polymorphonuclears, 68 per cent; lymphocytes, 32 per cent. Urine. — Very 
faint trace of albumin, occasional hyaline cast. 

Further Course of Cholecystitis. — This attack lasted for 3 weeks and gradually 
subsided by Sept. 5, 1918, when the patient was entirely free of gall bladder 
symptoms. 

Summary. — Apparently the patient was first seen towards the end of 
the course of a typhoid infection, at which time there was also an involvement of 
the gall bladder. This inflammation subsided, but the patient had a relapse of 
the typhoid as was evidenced by a positive blood culture on Aug. 30. 

Further Course of Disease. — With the subsidence of the fever on Sept. 14, the 
patient began to feel well and had no further complaints either subjectively or 
objectively until Oct. 12 (almost a month after normal temperature), when he 



34 



TYPHOID CARRIERS AND TYPHOID IMMUNITY 



had a typical attack of cholelithiasis requiring hypodermic administration of 
morphine. The following day he was slightly jaundiced; he had local symptoms 
of cholecystitis and consented to operation. Blood count. — White blood cells, 
8,80Q: polymorphonuclears, 44 per cent; lymphocytes, 56 per cent. 

Operation by Major Kammerer, Oct. 18, 1918. — Small gall bladder entirely 
enclosed within old adhesions which were in part ligated and in part torn away. 
Cystic duct ligated as closely as possible to entrance into common bile duct. 
Concentric hypertrophy of gall bladder; very small lumen; contained 1 large 
and several small irregular stones; gall bladder wall about f inch thick; cystic duct 
free. Culture from gall bladder contents showed Bacillus typhosus. 



TABLE XIV. 



Dates of cultures. 


Feces cultures. 


Urine cultures. 


Duodenal cultures. 


1918 








Sept. 5 


— 


— 




" 11 


— 


— 




a 17 


— 


— 


• 


" 20 






+ 


" 21 


— 


— 




" 23 


_ 


+ 




11 30 


— 


— 




Oct. 7 


— 


— 




" 20 


* 


-* 




' 27 


__* 


_* 




1919 








Jan. 1 


__* 






« G 






+• 


" 9 






-r* 


Feb. 10 






+* 


" 27 






+* 


May 11 






* 


" 18 






* 



* Subsequent to operation. 

Course after Operation. — Patient showed effects of shock after operation but 
soon recovered. About 1 week later, the wound showed some drainage of 
bile which kept up for 2 weeks and then ceased. On Nov. 16, 1918, the wound 
was entirely healed. Nov. 20, 1918, acute phlebitis of left leg which continued for 
2 weeks but then subsided; slight edema of left leg remained. Dec. 22, 1918, 
slight adenitis of left inguinal glands for 6 days. 

Results of stool, urine, and duodenal cultures are shown in Table XIV. 

Condition at Time of Writing (Feb. 20, 19 19). — Patient is feeling perfectly 
well, no trouble of any kind; has gained 17 pounds in weight, but has remained 
under isolation as a carrier. (He ultimately cleared up.) 



A. L. GARBAT 35 

While, as was seen above, it is possible to differentiate the intestinal 
carrier from the bile carrier, it is impossible by laboratory means to 
separate the two types of bile carriers, although it would be extremely 
important for therapeutic purposes to be able to do so. 3 Then, too, 
one cannot state absolutely whether in the liver carriers, the bacteria 
are located in the liver tissue or hepatic ducts. During typhoid fever 
the damage to the hepatic parenchyma in the form of the small areas 
of focal necroses might speak for the deposit of the bacteria in the 
liver; bacteria have been isolated from the walls of the larger divisions 
of the hepatic duct as well as from the liver substance itself. 

The most important advice is to try to establish the type of carrier 
during the early convalescence of the typhoid patient; i.e., at the be- 
ginning of the carrier state. At this stage, the intestinal carrier is 
readily differentiated from the bile carrier. If the carrier state con- 
tinues for a long time, various combinations of these three types may 
result, thus masking the characteristic features of the original type. 
An original bile carrier, for example (either gall bladder or liver), may 
ultimately resemble (although not really be) an intestinal carrier; 
that is, the bacteria would become so numerous that the feces would 
constantly show large numbers of them; possibly, too, the bacilli may 
lodge in the intestines on their way down and actually multiply there. 
A case in point occurred in our series. This patient (Ericksen) had the 
ordinary type of typhoid without any complications and ran a moder- 
ately high temperature for about 23 days. Of the usual number of 
stool cultures, only one specimen showed a few typhoid colonies on 
the Endo plate about 1 month after the beginning of normal tem- 
perature. During the following weeks, the stool cultures were again 
negative, although repeated duodenal tests revealed numerous typhoid 
bacteria in pure culture. After several months, the stools too began 
to show typhoid colonies in greater numbers, and then these gradually 

3 By the use of magnesium sulfate instillation into the duodenum, Lyon (25) 
has lately devised a method by which it is attempted to collect separately bile 
from different parts of the biliary apparatus. This should be tried in the future, 
and if proved practical, it may help us greatly in this differentiation of carriers. 
Instead of magnesium sulfate Stepp (26) injects a peptone solution into the duo- 
denum; these agents are supposed to cause a contraction of the gall bladder and 
expulsion of the bile into the duodenum. 



36 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

increased so that soon the larger proportion of the colonies on the Endo 
plates were typhoid; in other words, the picture resembled the char- 
acteristics of an intestinal carrier type. A more detailed history of 
this patient follows. 

Case 3. — Christen Ericksen, Register No. 518, age 25 years; born in Germany; 
sailor. 

Past History. — Nothing of importance is noted in personal history* 

Present Illness. — Started 4 weeks before admission to hospital with headache, 
pains in the abdomen, and constipation. 

Examination on Admission to U. S.A. General Hospital No. 12 on Aug. 13, 1918, 
by Lieutenant Sanders. The patient had no complaints except constipation; 
general condition good; tongue coated in center; scattered roseola over body. 
Heart. — Normal; pulse slow; blood pressure 105/65. Abdomen. — Flaccid. Liver. — 
Edge palpable just below costal margin. Spleen. — Palpable at costal margin. 
Temperature course. — Irregular fever from 101-104°F. for 13 days after admis- 
sion; temperature reached 104° only twice (total fever course approximately 24 
days). 

Early Laboratory Examination. — Blood culture. — Aug. 18, negative. Widal 
test. — Negative. Blood count. — White blood cells, 5,650: polymorphonuclears, 
59 per cent; lymphocytes, 41 per cent. Urine. — No albumin or casts. 

Further Course of Disease. — Patient did not feel very sick during the disease. 
After his temperature reached normal (Aug. 27, 1918) convalescence progressed 
rapidly and uneventfully. 

Results of stool, urine, and duodenal cultures are shown in Table XV. 

Condition at Time of Writing {Feb. 20, 1919). — Patient is eeling perfectly 
well; has gained 20 pounds in weight; has remained under strict isolation as a 
carrier. 4 

It thus seems plausible to assume that in this case the intestinal 
carrier condition was secondary to the biliary infection. The reverse 
condition may occur too; that is, an original intestinal carrier with 
no bacteria in the bile cultures made early during convalescence may 
ultimately show typhoid bacilli also in the bile. This transition will 
be explained in detail in the discussion of ascending infections of the 
gall bladder. 

4 On Mar. 24, 1919, cholecystectomy was performed. Cultures from the gall 
bladder contents showed Bacillus typhosus. Stool cultures were positive only 
once, 5 days after the operation, and subsequent stool and duodenal cultures were 
negative. 



A. L. GARBAT 



37 



TABLE XV. 



Dates of cultures. 


Feces cultures. 


Urine cultures. 


Duodenal cultures. 


1918 








Sept. 11 


— 


— 




" 20 


— 


— 




" 26 


+ 


— 


+ 


Oct. 3 


— 


— 




" 11 


— 


— - 




" 18 


— 






" 29 






+ 


Dec. 2 






+ 


" 31 


+ 






1919 








Jan. 2 


+ 




4- 


" 6 


+ 






" 12 


— 






" 21 


+ 






Feb. 4 






+ 


" 11 


+ 







How Do the Typhoid Bacilli Reach the Gall Bladder? 

Three possibilities can be given as answers. 

1. The generally accepted path for the conveyance of the typhoid 
bacillus to the gall bladder is by way of the blood to the liver and then 
into the bile. The damage to the hepatic parenchyma during the 
typhoid illness may more readily allow the passage of the bacillus 
into the bile. This injury to the liver tissue is not, however, essential 
for it has been repeatedly shown (Blachstein (27), Welch (28), and 
Doerr (29)) that in rabbits which have been inoculated intravenously 
by typhoid bacilli, the bacteria regularly appear in the gall bladder 
and often as early as 8 hours after inoculation. Doerr demonstrated 
that when the hepatic duct was ligatured the bile invariably remained 
sterile. Also when the cystic duct was ligatured, no bacilli could 
be demonstrated in the gall bladder. Once the bacteria reach the 
gall bladder, they grow there as readily as in a culture tube, finding 
a suitable medium which is periodically renewed and eliminated. If 
the foci in the liver (or ducts) clear up, then the carrier remains 
only a gall bladder (bile) carrier; on the other hand, the liver infec- 
tions may continue and then the patient persists also as a liver (bile) 



38 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

carrier. The factors which govern this are unknown. While the 
above experiments proved that the bacilli travelled by the bile and 
not by the blood vessels of the gall bladder itself, there are observers 
who believe that: 

2. The typhoid bacilli may enter the bile by the blood capillaries 
in the submucosa of the gall bladder wall where they possibly form em- 
boli. In a patient who died during the first weeks of his typhoid ill- 
ness, Koch (30) by careful histological examination found nests of 
typhoid bacilli in the papillae of the inflamed mucosa of the gall 
bladder wall. These bacteria lay in close proximity to the capillaries 
and were therefore assumed to be capillary emboli. These findings 
were also corroborated in animals (Chiarolanza (31)). 

3. The ascending route of infection of the gall bladder by way of 
the common bile duct has not been received with general favor. The 
author, however, desires to record the following case as evidence that 
this mode of infection is possible. 

Case 4. — Gustave Haak, Register No. 524, age 44 years; born in Germany. 

Past History. — Nothing of importance is noted in his habits, family history, 
or venereal history. Has never been sick before. 

Present Illness. — Was at the hospital at Hot Springs since Aug. 2, 1918, with 
headache and fever. On July 26 had received 1 antityphoid inoculation. 

Examination on Admission to U.S.A. General Hospital No. 12 on Aug 13, 1918, by 
Lieutenant Wenner. General condition good; tongue dry and coated. Hear!. — 
Sounds fair; dicrotic pulse. Lungs. — Numerous rales. Abdomen. — Soft. Liver. — 
Edge felt one finger's breadth below costal margin. Spleen. — Just palpabe and 
lender. Temperature course. — On admission, temperature was 104. 6°F., but the 
fever came down gradually so that it reached normal on Aug. 28, 1918, and 
remained so (total fever course approximately 26 days). 

Early Laboratory Examination. — Blood culture. — Aug. 19, negative. Blood 
count. — White blood cells, 12,000: polymorphonuclears, 64 per cent; lymphocytes, 
36 per cent. Urine. — Faint trace of albumin, occasional hyaline cast. 

Further Course of Disease. — Patient did not feel sick during fever course. After 
the temperature reached normal, convalescence progressed rapidly and un- 
eventfully. 

Results of stool, urine, and duodenal cultures are shown n Table XVI. 

Condition at Time of Writing (Feb. 20, 1919). — Patient is feeling perfectly well; 
has gained 31 pounds in weight. 

In recapitulation, we had a patient who from the very beginning of his con- 
valescence, 5 days after normal temperature, began to show an almost pure 
culture of typhoid bacilli in the feces which continued thus right along for 6 



A. L. GAEBAT 



39 



months (up to the time of writing). In spite of these early positive stool cul- 
tures, 4 duodenal cultures were made during the first 2 months after normal 
temperature and in none of them were typhoid but only colon bacilli found, 
although large quantities of pure bile were obtained for each culture. 



TABLE XVI. 



Dates of cultures. 


Feces cultures. 


Urine cultures. 


Duodenal cultures. 


1918 








Sept. 2 


+ 


— 




" 11 


— 


+ 




" 14 


+ 


— 




" 23 


+ 


— 




" 25 






— 


" 30 


— 


— 




Oct. 10 


+ 


— 




" 12 


+ 


— 




" 15 






— 


« 19 


+ 






" 23 






— 


" 26 


+ 






" 29 






— 


Nov. 9 


— 






" 16 


+ 






" 25 


— 






Dec. 2 


+ 




+ 


" 16 


+ 






1919 








Jan. 2 


+ 


— 


— 


" 6 


+ 




+ 


" 12 


+ 






" 21 


+ 






" 23 






+ 


Feb. 2 


+ 






" 4 






+ 


" 11 


i 






" 20 






+ 



These findings proved the patient a true intestinal carrier. The fifth duodenal 
culture, however, which was repeated in 1 month showed few typhoid colonies 
amongst the colon bacteria. 1 month later, the typhoid colonies in the bile were 
more numerous and the future duodenal cultures continued to show a profuse 
pure growth of typhoid bacteria. 



40 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

Those opposed to the general principle of ascending infections of the 
gall bladder, may voice the criticism that the typhoid bacteria cul- 
tured from the duodenum in the case described did not come from the 
gall bladder, but had found their way from the large intestine into 
the duodenum and were only washed out from the duodenum by the 
bile which came from a non-infected gall bladder. Naturally, the 
only positive proof in answer to this criticism would be a culture 
directly from the gall bladder. 5 However, the writer feels that the 
complete absence of typhoid bacilli in the bile at first, then the slight 
invasion, and finally the almost pure culture, speaks for the infection 
of the bile by the ascending route. In this way, a primary intestinal 
carrier becomes also a bile carrier. 

Similarly, the principle of ascending infections may possibly account 
for a small percentage of liver carriers who originally may not have 
been liver carriers, but only gall bladder carriers. Since bile is pro- 
duced in the liver almost constantly, it is present in the ducts all the 
time but in a stagnant condition, because it flows into the duodenum 
only intermittently. It should not be difficult therefore for bacteria 
to invade the bile ducts of the liver or the liver tissue itself when 
some infected bile from the gall bladder is dammed back through the 
Cystic duct into the hepatic ducts and liver. Especially is this a 
possibility the longer the bacteria have been harbored in the gall 
bladder. This view was brought out forcibly in three patients at the 
Walter Reed Hospital kindly shown to the writer by Lieutenant- 
Colonel Nichols. They were all bile carriers; two of them had per- 
sisted for 12 and 13 years and one for only 12 months. Cholecystec- 
tomy and excision of the cystic duct cured the patient with the more 
recent carrier condition but had no effect whatever upon the old 
carriers. The duodenal contents of the latter showed as many typhoid 
bacteria after as before the cholecystectomy. The author does not 
wish to give the impression that the ascending route of infection, 

5 Since the time of this original manuscript, Patient Haak was operated upon. 
On Mar. 18, 1919, a cholecystectomy (without drainage of the common bile 
duct) was performed by Captain William S. Long. As was predicted, the gall 
bladder contents showed a pure growth of typhoid bacilli. 1 month later 
(Feb. 21 and 24), both the stool and duodenal cultures were still positive for 
Bacillus typhosus. Apparently the infection by this time had extended higher up 
into the liver or bile ducts. 



A. L. GARBAT 41 

either for the gall bladder or liver carriers, is the frequent or the 
general occurrence, but merely wishes to point out that this path of 
infection is undoubtedly a possible one. 

Surgical Treatment of Carriers. 

Dehler (32) was the first to suggest operative interference directed 
towards the cure of the carrier state. In his first 2 patients only 
drainage of the gall bladder (cholecystostomy) was resorted to. In 
one of these patients typhoid bacilli were isolated in small numbers 
from the feces several months after operation. 

Grimme (33) next reported that he had had the operation of chole- 
cystectomy performed in a female asylum carrier. 15 days after the 
operation, Bacillus typhosus was found in the feces, but not at a later 
period. 

Since then, cholecystectomy has been adopted as the routine 
surgical procedure for the cure of carrier conditions, but the results 
have not been uniformly successful (Lorey (34), Loele (35), Huismans 
(36), Kamm (37), Fromme (38), Dehler (39), Leary (40), Nichols, 
Simmons, and Stimmel (41)). The cause for the failures is evident if 
the classification of the various types of carriers is kept in mind. 

Formerly when cholecystectomy did not cure a typhoid carrier, it 
was usually attributed to the fact that the cystic duct had not been 
completely excised. The bacteria were supposed to continue to 
multiply in the duct as a pocket where bile was retained, simulating 
a gall bladder but on a very much smaller scale. While this explana- 
tion may account for the failures in some of the early cholecystec- 
tomies, in recent times the surgeons are certain to excise the cystic 
duct completely. The author has personally observed 2 such com- 
plete excisions where the carrier state remained unaffected. The 
present study has shown that there are two additional reasons which 
may account for the failure: (a) Hepatic (or duct) carriers. These 
patients will not be relieved by cholecystectomy because the infection 
continues higher up. (b) Intestinal carriers. These too will be influ- 
enced in no way by complete excision of the gall bladder. The bac- 
teria will continue to grow somewhere in the intestines. 

Therefore, if a carrier is diagnosed as an intestinal one, operative 
treatment should not be resorted to. Only bile carriers should be 



42 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

treated surgically and the type of bile carrier more amenable for 
operation is the gall bladder type. Unfortunately, it is impossible 
to differentiate absolutely between the gall bladder and hepatic 
types. 3 Taking this into consideration, the author advises instead of 
cholecystectomy alone, a cholecystectomy plus long continued 
drainage of the liver through the hepatic duct. The reasons for this 
are both diagnostic and therapeutic. After the drainage of the bile 
has set in, it is a simple matter to take cultures of the bile coming from 
the liver through the rubber drainage tube and ascertain whether 
typhoid bacteria are present or not. At the same time, the stool 
should be examined as control. If repeated cultures from the bile 
prove that the liver or ducts are not infected, drainage may be stopped 
and the wound may be allowed to close quickly. On the other hand, 
if the bile is proved to contain typhoid bacteria, drainage should be 
prolonged with the hope that in this way the infection may clear up. 

Drainage of the common bile duct outside of the body has the ad- 
vantage over the natural flow into the intestines in that it keeps the 
intestines free of typhoid bacteria and in that a greater quantity of 
bile is drained. Physiology of bile excretion teaches us that although 
bile is formed more or less continuously, it enters the duodenum 
only periodically during the time of digestion. The bile during the 
intervening periods is prevented from entering the intestines because 
the opening of the common bile duct into the duodenum is closed by 
a sphincter. The secretion, therefore, backs up into the liver. No 
bile appears in the duodenum as long as the stomach is empty. When 
a meal is taken, the entrance of the chyme into the duodenum is 
followed by an ejection of bile. It would seem therefore that each 
gush of chyme into the duodenum excites by reflex action an inhibition 
of the sphincter and the opening of the common bile duct. By means 
of hepatic drainage, the bile which is formed all the time is also ex- 
creted all the time, thus constantly flushing the infected area and 
allowing of no stagnation where the bacteria can grow more readily. 
The possibility of ridding the liver or ducts of bacteria seems in this 
way a little more hopeful. 

Another important consideration is the time of operation. When 
surgical measures are contemplated, they should be done early when 
the original type of the carrier state remains uncomplicated. If the 



A. L. GARBAT 43 

typhoid carrier presented no clinical symptoms referable to the gall 
bladder during the acute stage of the disease or convalescence, 6 
months from the onset of normal temperature is a reasonable time to 
wait for nature to cause the disappearance of typhoid bacteria 
from the bile before operating. On the other hand, if symptoms of 
cholecystitis or cholelithiasis 6 were present during any stage of the 
illness and duodenal cultures persistently showed typhoid bacteria, 
operative interference may be undertaken even earlier, because these 
patients usually become chronic carriers. It is to be remembered, 
however, that not all patients who present gall bladder symptoms 
during typhoid fever become carriers, so that operation cannot be 
justified from the carrier standpoint unless duodenal cultures show 
typhoid bacteria. 

The author observed 4 carriers in each of whom cholecystectomy 
(without drainage) was performed. In 2 (Karpinsky and Ericksen) 
the carrier condition disappeared immediately after operation. In 1 
of these (Ericksen) only 1 stool culture made 5 days after operation 
showed typhoid bacteria, while subsequent cultures both of the feces 
and duodenum were negative. These were examples of pure gall 
bladder carriers, the type most amenable for operation. In the third 
patient (Lehman) the duodenal cultures remained positive for four 
months after operation, although repeated stool examinations were 
negative. Except for the duodenal cultures, this case would have 
passed as a surgical cure and been permitted to leave the hospital be- 
fore he ceased to be a menace to the community. This is an example 
of a liver carrier, usually not helped by operation. (The writer is 
informed that ultimately, 8 months after operation, 2 consecutive 
negative duodenal cultures were obtained.) In the fourth patient 
(Haak) both duodenal and stool cultures continued positive after 
operation. This is an example of an original intestinal carrier with 
secondary bile infection. 

It is to be assumed that in many instances consent for operation 
will not be obtained from the apparently healthy carriers; but when 
it is, our classification and study of the various types should give us 
better results than we have had in the past, or abetter understanding 
of our failures. 

6 The relationship between symptoms of cholecystitis during the typhoid fever 
and a later carrier state is more fully discussed in the next section. 



IV. PREDISPOSING FACTORS TO THE TYPHOID CARRIER STATE WITH 

SPECIAL REFERENCE TO CHOLECYSTITIS AND 

CHOLELITHIASIS. 

Why Do Some Patients Harbor Typhoid Bacteria in the Gall Bladder 

Longer Than Others? 

For this study, the 21 patients who continued to show a positive 
bile culture were selected. A detailed analysis was made of the 
clinical course of their disease, in order to discover any possible pre- 
disposing elements to the carrier state. The following factors 
were investigated: (a) blood culture, (b) length of illness, (c) se- 
verity of illness, (d) prophylactic inoculation, (e) cholecystitis, 
(J) cholelithiasis. 

Did These Patients with Positive Duodenal Cultures Have a Positive 
Blood Culture during the Active Stage of the Disease? 

This question is taken up because some readers may ask it. The 
author, however, feels that all typhoid cases at one time or another 
during the active stage of the disease have had a bacteremia; and, 
especially those who later developed a positive bile culture. The bac- 
teria must reach the gall bladder by way of the blood (the only ex- 
ception to this is possibly the bile carrier due to ascending infection) . 
It is surprising to note, nevertheless, that in only 4 of 19 cases was a 
positive blood culture reported (2 patients had normal temperature 
and no blood culture was taken) . Table XVII shows the time during 
the course of the disease when these negative blood cultures were 
obtained. 

TABLE XVII. 



No. of cases. 


No. of cultures. 


Week of disease when culture 
was taken. 


3 
3 

7 

2 


2 
2 
1 
1 


1st 

2nd 
3rd 

4th 



44 



A. L. GARBAT 



45 



While a negative blood culture did not mean that there were no 
bacteria in the circulation, it did imply that there were no excessive 
numbers of them and that they did not persist in the blood over an 
extended period. 

Of the positive cultures, there were three obtained during the 
second and one during the third week. 

No relationship, therefore, can be discovered between a positive 
or negative blood culture as a predisposing factor towards the typhoid 
carrier state. Only if a great majority of the cases had shown a 
positive culture and especially at a stage of the disease when a positive 
culture is unusual, would it have been permissible to draw any 
conclusions. 

Does the Length of the Disease Have Any Bearing upon the Tendency 
of the Bacilli to Persist in the Bile? 

The length of the illness was reckoned in terms of the number of 
days of fever; i.e., from the day when the patient went to bed to 
the day when the temperature came down to below 100° and stayed 
there. These fixed dates have always seemed to the author a much 
more reliable method for determining the actual length of the disease 
than the way usually estimated; namely, from the time the patient 
first began to feel ill, to some arbitrary day during convalescence, 
such as when the patient was able to get out of bed or leave the 
hospital, etc. In our 21 cases the duration of fever is shown in Table 
XVIII. 





TABLE 


xvin. 




No. of cases. 


Duration of fever. 


No. of cases. 


Duration of fever 




weeks 




weeks 


3 


2 


4 


5-6 


7 


3-4 


1 


6-7 


2 


4-5 


4 . 


7-8 



The average case of typhoid fever runs a temperature for about 
4 weeks. It is interesting to note that the majority of the typhoid 
carriers did not have a shorter acute illness but rather a longer one 
than the general average. The possibility must be considered that 



46 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

this protracted course is not a predisposing factor to a carrier con- 
dition but one resulting from the ever existing infected bile in the 
biliary tract and intestines. In this connection it may be mentioned 
that among these 21 patients there were 4 cases with relapses and 4 
cases with recrudescences; i.e., 38 per cent. This percentage is rather 
high when compared with the 18 relapses and 18 recrudescences 
(22 per cent) which occurred amongst the total number of cases 
(164). From the same figures it may be seen that 22 per cent of all 
the patients who suffer from either a recrudescence or relapse tend 
to become typhoid carriers, temporary or permanent (8 out of 36). 

Does the Severity of the Disease Have Any Bearing upon the Predis- 
position to the Typhoid Carrier State? 

We differentiated strictly between the length of disease and severity 
of infection. One may have a long, but at the same time mild in- 
fection and vice versa. The same holds true for a short illness. 
In grading the degree of each patient's illness, we merely took into 
consideration the severity of the infection during the acute stage. 
A + + + + scale was used. 

+ + + + signifies the severest type of infection where prognosis was very 
grave from the start and the patient died. 

+ + + signifies a seriously ill patient with a doubtful prognosis during his 
illness but one who finally recovered. 

+ + is the usual sick typhoid. 

+ means a very mild infection. 

— means that the patient was clinically not ill at all; were it not for the labora- 
tory findings, the disease would have remained unrecognized. 

Of the 21 patients with positive duodenal cultures: 

1 was graded — (not sick at all.) 
11 were " 4- 
5 " " + + 
4 " " +++ 

Of the 4 patients who became permanent typhoid carriers: 

3 were graded -j- 
lwas " + + 

It is evident that 16 of the cases, approximately 80 per cent, were 
only + and + + types of infection. This proportion is practically 



A. L. GARBAT 47 

the same as existed between the entire number of + and ++ cases 
and the total number of typhoid cases at the hospital. The point 
of importance that the author desires to emphasize is that it is not 
necessarily the severe types of infection that are prone to become 
carriers. 

Are Patients Who Have Received Antityphoid Inoculations and Have 

Been Infected in Spite of the Inoculations Less Liable 

to Become Typhoid Carriers? 

Of the total number of typhoid patients treated at the hospital: 

38.0 per cent had received no inoculation. 

41.0 " " " " onlyl " 

11.8 " " " " 2 inoculations. 

2 2" " " " 3 " 

8.0 " " unknown. 

Of the 21 patients who persisted with typhoid bacteria in the bile: 
45 per cent had received no inoculations; 40 per cent had received only 
one inoculation; and 15 per cent had received two inoculations. None 
had a complete course of inoculations. Those who had received 
only one or two prophylactic injections did not complete their third 
injection because the illness had already set in, or set in immediately 
after the last inoculation. While the above figures may speak some- 
what for the beneficial influence of inoculations, conclusions as to 
their value cannot be drawn too closely. 

Cholecystitis. 

In a study of the cases which manifested symptoms of cholecystitis 
either as a complication during the disease or as a sequel during con- 
valescence, a very close relationship to the carrier state was noted. 
Out of 178 proved typhoid cases, 8 (4.5 per cent) had definite clinical 
evidence of cholecystitis during the acute illness. 

A tabulation of the findings in 7 of these patients is given in 
Table XIX (the eighth died of pneumonia several days after admis- 
sion before the laboratory examinations could be made). 



48 



TYPHOID CARRIERS AND TYPHOID IMMUNITY 



TABLE XIX. 



6 
u 

CO 

U 


Name. 


4) 

hi 
3 
*-) 

"3 

u 

n 
u 
a 
u 

Ph 


H 

3 

u 

*e3 
c 
u 

73 
O 

3 
P 


Direct culture from 
O O O O + + + gall bladder. 

— h * * 


n 
*w 

.2 
IS 

■4-1 

A 

o 

+ 

+ 







a 

# o 

•3 

3 

8 

h 

*c 
o 

+ 
+ 

+ 

+ 
+ 


Results. 


1 

2 

3 

4 
5 
6 
7 


Karpinsky . . 
Lehman 

Kobe....... 

Bergenthal.. . 
Jannssen 


+ 

+ 
+ 


+ 

+ 
+ 





Cured (cholecystectomy). 

Remained carrier even after chole- 
cystectomy, due to liver infection. 

Died (cholecystitis and complicating 
myocarditis and pneumonia). 

Cured (temporary carrier). 

tt It u 
iC It tt 

" (never proved a carrier). 



* Operation, 
t Post-mortem. 

Thus it is noted that of the 7 patients who manifested symptoms 
of cholecystitis 6 ultimately became typhoid carriers. The bacilli 
were found in the excised gall bladder of 3, in the duodenal contents 
of 2, and in the feces of 1. Some of the discrepancies of the above 
table require explanation. 

Case 1 {Table XIX) showed no typhoid bacilli in the duodenum because as 
was proved by operation the cystic duct was occluded by a large stone. At 
the time when the positive stool was obtained, it was probable that the cystic duct 
was either not yet completely occluded or was only intermittently occluded. 

Case 3 {Table XIX) never showed typhoid bacilli in either the feces or duo- 
denum. The patient had recurrent attacks of cholecystitis and died during one 
of these periods of a myocarditis and a complicating pneumonia. A short review 
of this man's history will disclose the evidence of the carrier condition. 

He was admitted to U.S.A. General Hospital No. 12 on Aug. 13, 1918; had been 
at the hospital in Hot Springs since Aug. 1, 1918; had typical clinical typhoid 
with marked intestinal hemorrhages and definite myocarditis. 

Aug. 13 to 26. Temperature gradually came down to normal. 

Aug. 26 to Sept. 1. Temperature normal. 

Sept. 1 to Sept. 21. Typical relapse with blood in stools and temperature as 
high as 104.8°F., gradually coming down. 

Sept. 21 to Oct. 9. Temperature normal; patient out of bed. 



A. L. GARBAT 49 

Oct. 9 to Oct. 18. Another relapse but milder than the first. 

Oct. 18 to Nov. 15. Temperature normal; patient out of bed. 

Nov. 15 to Nov. 21. Temperature up to 103°, condition simulating relapse, 
with symptoms of cholecystitis for the first time. 

Nov. 21 to Jan. 2. Temperature normal; patient out of bed. 

Jan. 2 to Jan. 30. Temperature up to 103.5°, with renewed symptoms referable 
to cholecystitis associated with lobar pneumonia; death. 

Laboratory Findings. — Widal test. — Positive on admission. (Patient had 
received no inoculation.) Blood cultures. — 6 negative. Stool. — At no time posi- 
tive for typhoid bacilli. Urine. — Typhoid bacilli found only once, Nov. 22, 1918. 
Duodenal culture. — Oct. 10, negative. Autopsy report. — The gall bladder region 
presented old dense fibrous masses which bound the liver to the diaphragm and 
formed one large mass of the gall bladder, pylorus, duodenum, and pancreas. 
After very difficult dissection, the gall bladder was found deeply buried. It was 
the size of a pigeon's egg and was contracted down upon four yellow apparently 
cholesterol stones which entirely filled the cavity. The gall bladder contained 
a little mucus but no bile. The cystic duct was obliterated. 

Cultures from the interior of the gall bladder showed Bacillus typhosus; at the 
same time, cultures from the duodenum, large intestine, liver, spleen, lungs, 
abdominal fluid, etc., showed no typhoid bacilli. The apparent discrepancy 
between the positive culture from the gall bladder interior and negative culture 
from the duodenum before and also after death are readily explained by the com- 
plete shutting off of the cystic duct both by the stones and adhesions. The bile 
which was examined during life did not come through the gall bladder but directly 
from the liver which was not infected. The bacteriological conditions in this 
patient were identical with those of patient Karpinsky discussed in the chapter 
on bile carriers. 

Cases 4 and 5 {Table XIX) showed typhoid bacteria in the bile by duodenal 
culture. 

Cases 6 and 7 {Table XIX) had the most severe attacks of cholecystitis. Re- 
peated attempts at duodenal cultures were unsuccessful. In Case 6 the duodenal 
tube was passed four times but on no occasion was bile obtained. Similarly, 
in Case 7 (Table XIX), three attempts were made and on one occasion only bile- 
stained fluid, but not true bile, was recovered. This did not show typhoid bacilli. 
It is very unusual to meet with such difficulty. The failures were probably due 
either to reflex spasms of the pylorus or true pyloric obstruction from adhesions 
of the gall bladder. The frequent vomiting which these patients suffered from 
substantiated this view. The fact that the stool examinations in Case 7 did not 
reveal typhoid bacilli does not, in the light of experiments already discussed, ex- 
clude the possibility of their existence in the bile. It is possible, too, that here 
again we were dealing with a contracted and obliterated gall bladder where the 
typhoid bacilli could be recovered only from the interior of the gall bladder. 



50 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

In recapitulation, it is noted that of 7 patients who had attacks of 
cholecystitis during the course of their typhoid fever, 6 became definite 
typhoid carriers, either temporary or permanent, with typhoid bac- 
teria in the bile or feces; the 1 other patient was inadequately ex- 
amined. 

These facts assume importance in the light of the surgical therapy 
in carriers. Cholecystectomy (plus drainage of liver) for typhoid 
cholecystitis becomes warranted very much earlier when we have 
the additional knowledge that a typhoid carrier state results in most 
cases of cholecystitis. Once the symptoms of cholecystitis have 
manifested themselves, recurrent attacks of pain and fever are almost 
bound to arise as long as live typhoid bacteria remain in the gall 
bladder. This is probably the state of affairs that exists in patients 
operated upon for cholecystitis many years after the typhoid illness, 
in whom typhoid bacilli are unexpectedly found in the gall bladder. 
These individuals had undoubtedly been carriers during all that 
interval. Especially in these patients should duodenal cultures 
be made as soon after the operation as feasible, in order that a liver 
carrier may not be overlooked. 

If operation for typhoid cholecystitis is delayed and attacks recur, 
very marked adhesions are developed which may make surgical 
interference very much more difficult or even dangerous. Such 
would have been the case in our patient Kobe who died of a compli- 
cating pneumonia and myocarditis before the operation was under- 
taken. Even at post-mortem it was impossible to dissect out the 
gall bladder without great damage to the related organs. 

Many of the so called prolonged cases of typhoid fever or the 
cases with frequent relapses are probably typhoid infections of the 
gall bladder, although the local process may be so mild that definite 
symptoms of cholecystitis are either overlooked or missing. 

On the other hand, not all patients of our series who became carriers 
had manifested symptoms referable to the gall bladder at some- 
time during the course of the acute disease. Of our 21 patients with 
persistent positive bile cultures, only 7, or 33 per cent, had presented 
gall bladder symptoms during the typhoid illness. Amongst the 14 
others who did not show such symptoms, 2 were the most persistent 
carriers. 



A. L. GARB AT 51 

Pathology of the Gall Bladder in Carriers. 

This division of carriers on the basis of former gall bladder involve- 
ment explains very logically the two types of gall bladders met with 
in carriers. In those who do not manifest any gall bladder disturb- 
ances, the gall bladder may show only very slight pathological changes. 
The normal glistening appearance of the peritoneal coat may be dulled, 
the wall may be slightly thickened, the entire organ may not be en- 
larged, and on being cut open the mucous membrane may present 
just a thickened or congested appearance. Microscopically, the 
different layers of the wall may be sharply outlined, but infiltrated 
by lymphocytes and few leucocytes. In these cases the gall bladder 
acts purely as a test-tube containing the bile medium in which the 
typhoid bacteria propagate without affecting the gall bladder itself. 
In the second type, the gall bladder may present the inflammatory 
changes of various grades of cholecystitis. The entire organ may be 
buried in dense adhesions, the walls may be § to J inch in thickness, 
and on section the entire normal gall bladder appearance may be 
obliterated and replaced by a mass of fibrous tissue infiltrated by 
lymphocytes and polynuclear leucocytes. In between these two 
extremes, all degrees of pathological changes may exist. 

Cholelithiasis. 

The relationship between cholelithiasis and typhoid fever has 
already stimulated such a vast amount of literature that only the 
outstanding features can be reviewed here. The discovery of the 
typhoid bacillus in cases of cholecystitis and cholelithiasis long 
after recovery from the primary infection, was made many years 
previous to the recognition of the typhoid carrier. In 1892 Naunyn 
(42) had observed that gall stone troubles frequently occurred in 
persons who had suffered from typhoid fever. Lentz (43) in 1905 
was the first to direct attention to the association of gall bladder com- 
plaints with the carrier state. Since then it has been frequently shown 
that quite a large number of carriers suffer from gall stones, while 
in others, though symptoms may have been absent, a condition 
of cholelithiasis has been very frequently found, whether on examina- 
tion, post-mortem, or at operations directed towards bacteriological 
cure of the carrier condition. 



52 TYPHOID CARRIERS AND TYPHOD3 IMMUNITY 

In our 21 carriers there were 3 (14 per cent) in whom gall stones 
were discovered. 

(1) Karpinsky. — Operation about 7 to 8 weeks after onset of illness; 21 
stones; 4 very hard and about 1 inch in diameter; 1 about f inch in diameter; 5 
about | inch in diameter; the rest about \ inch in diameter; they were all hard 
and faceted. 

(2) Lehman. — Operation 2 months after onset of illness; 1 large, hard, mul- 
berry-shaped gall stone about \\ inches in diameter and several very small softer 
stones (all calculi of cholesterol). 

(3) Kobe. — Post-mortem about 6 months after admission to hospital; 4 stones 
(cholesterol) ; 2 large stones each about 1 inch in diameter and 2 smaller ones about 
| inch in diameter. 

Forster (44) in an analysis of several hundred carriers found the 
same percentage (14 per cent) of gall stone sufferers. The remaining 
85 per cent undoubtedly have some disease of the gall bladder, al- 
though they give no clinical indication thereof. This accords well 
with our knowledge that 90 per cent of all gall stone cases present no 
symptoms during life. These facts brought to the writer's considera- 
tion the question whether it is the chronic carrier infection of the gall 
bladder which gives rise to the formation of the stones, or vice versa 
whether it is a preexisting cholelithiasis which predisposes the typhoid 
patient to the development or continued existence of the carrier 
state. X-ray examination of the gall bladder region was made in 
each of our 21 carriers, but in only 2 were the x-ray findings suspicious 
of stones. 

These negative results agree fully with the fundamental findings 
of Blachstein (27) and Welch (28) who showed that no locus minoris 
resistentice in the gall bladder was essential for the development of 
the carrier condition; mere intravenous inoculation of typhoid bacilli 
in rabbits is followed by the presence of these organisms in the gall 
bladder for a very long while — in one instance for 128 days. While 
these experiments disprove the absolute necessity of a previous gall 
bladder injury for the formation of a carrier condition, they do not 
speak against the logical assumption that those patients with a 
previous cholelithiasis are more prone to become carriers, or to remain 
such for a longer period of time. 

As for the relationship between the typhoid bacillus and actual 
gall stone formation, here also a division of opinion exists. While 



A. L. GARBAT 53 

the typhoid bacillus has been repeatedly isolated from the center of 
gall stones both in cases of cholelithiasis operated on by the surgeon 
and in chronic carriers either at operation or at autopsy (Anton and 
Fiitterer (45), Droba (46), Blumenthal (47), Levy and Kayser (48)), 
no definite decision has yet been reached as to whether the typhoid 
bacillus directly excites the formation of the gall stone and forms a 
nucleus for it or whether the stone is preformed and later penetrated 
by the typhoid bacillus. Conforming with these opposing views, 
some authorities (e.g. Bacmeister (49) ) believed that organisms were 
only to be found in old stones into which they had penetrated, while 
other observers (e.g. Cushing (50)) held that only recently formed 
stones contained bacilli. As is so often the case in medicine, 
experimental data were furnished by both sides in support of their 
contentions. 

On the other hand, gall stones were placed in broth and bile cultures 
of the Bacillus typhosus and also of Bacillus coli, and these bacteria were 
then recovered from the center. Gilbert and Fournier (51) found that 
bacilli wandered in when stones were of cholesterol and not in the 
case of other stones; but then, it is usually the cholesterol stone which 
develops during typhoid fever. The Aschoff school has recently 
shown that the cholesterol content of the blood is increased in all 
long continued acute and subacute septic or pyemic processes and 
therefore concludes that in typhoid the stones are found in the gall 
bladder because of stagnation of the bile. The bacteria may later 
travel into the stone and thus bear no etiological relationship to the 
stone. 

On the other hand, embryonic gall stone formation may be observed 
in test-tubes containing bile cultures of either typhoid or colon 
bacilli. Bacmeister found that Bacillus coli. Bacillus typhosus, 
Bacillus proteus, and especially Bacillus pyocyaneus could cause a 
precipitation of cholesterol from bile. Even true concretions were 
found after prolonged growth of the bacteria in this medium. 

Then, too, gall stone formation has been observed after injecting 
heated bouillon cultures of typhoid bacilli into the gall bladders of 
rabbits (Gilbert and Fournier (52)). Doerr (53) has met with two 
concretions of the size of a lentil in a rabbit which had been injected 
intravenously with typhoid bacilli 40 days before. Gay (54) noted 



54 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

gall bladder concretions in some of his carrier rabbits, and Richardson 
(55) succeeded in experimentally producing ' concretions in rabbits 
by the injection into the gall bladder of agglutinated typhoid bacilli. 

In the light of these varied experimental results, there can be no 
doubt that an attack of typhoid fever predisposes a patient to the 
formation of gall stones, but at present one cannot be certain how 
far this formation is contributed to by other factors. It is probable 
that in certain instances the precipitation of cholesterol comes first, 
to be followed by the entrance of bacteria, while in other instances the 
stagnation of the bile may cause a precipitation of the cholesterol 
around a nucleus of epithelial cell debris and typhoid bacteria. 

The stones formed during typhoid fever may reach a large size in 
a comparatively short time. In one of our carriers (Kobe) 4 choles- 
terol stones were removed from the gall bladder 6 months after 
admission for the acute typhoid. 2 were about 1 inch in diameter 
and 2 about J inch in diameter; typhoid bacteria were recovered from 
the center of all. The size of the stones seemed very much larger 
than would be expected to develop in 6 months. 

One should not, however, fall into the fallacy of attributing to the 
typhoid infection all stones found in a patient who gives the history 
of a recent or old typhoid. In Case 2, the large stone-hard choles- 
terol calculus about 1| inches in diameter undoubtedly existed 
long before the typhoid illness which was only 2 months old. The 
2 smaller and softer stones, also of cholesterol, were probably of typhoid 
origin. Unfortunately the stones were dropped into formalin and 
cultures made from the center of the stones the next day were found 
sterile. It may be that in typhoid patients with preexisting choleli- 
thiasis, the tendency to the formation of stones being already present, 
the added element of the typhoid infection predisposes the patient 
to additional and more rapid gall stone formation. 



V. TYPHOID URINE CARRIERS. 

A. Irregularity and Intermittens y of Bacilluria; New 
Method for Detecting Urine Carriers. 

The excretion of typhoid bacilli in the urine from typhoid con- 
valescents has been studied in 164 patients and entailed approxi- 
mately 2,000 urine cultures. According to the army rule, every 
patient was kept under strict typhoid precautions until 3 consecutive 
urines and stools at intervals of 6 days were free of typhoid bacteria. 
The first culture of the urine was generally made when the patient's 
temperature was nearing normal or had already reached normal. It 
was found that the excretions of typhoid bacilli in the urine during 
convalescence followed one of three courses: 

(a) Urines which were at no time positive (3 or more consecutive 
urines at intervals of 6 days being negative). This comprised 51 per 
cent of the patients (84 out of 164). 

(b) Urines which were at first positive and remained so for a shorter 
or longer time, then became negative and remained so. This comprised 
25 per cent of the patients (41 out of 164). For example, patient 
Gutte: Sept. 13, 18, 29, positive; Sept. 30, Oct. 7, 26, Nov. 2, 
negative. 

(c) Urines which changed, sometimes positive, at other times nega- 
tive, then positive only to become negative again, etc. This com- 
prised 23 per cent of the patients (39 out of 164). As typical of such 
irregularity of findings in the routine urine specimens, results with 4 
patients are cited in Table XX. 

It is these changing urines which particularly interested the writer. 
The question arose whether it was possible that 3 isolated specimens 
of urine examined at intervals of 6 days could show no typhoid bacilli, 
while other specimens taken in between or even later on contain 
typhoid bacteria. The great danger of overlooking urine carriers 
would thereby be offered. As the routine cultures were usually made 
of specimens passed in the morning, the first question to decide was 
whether the time of voiding had any influence upon the result. 12 

55 



56 



TYPHOID CARRIERS AND TYPHOID IMMUNITY 



patients were selected and every specimen voided by each patient 
was carefully collected and cultured separately. All precautions for 
obtaining a sterile specimen were observed: the head of the penis 
was washed with bichloride solution; the first part of the urine voided 
was not kept but used for washing out the urethra; the last part was 
voided directly into a sterile bottle. At this time, cultures were made 
only on Endo plates; 1 cc. of each specimen was spread in a thin layer 
over the entire surface of the media and incubated for 24 hours. 



TABLE XX. 





Urine examinations. 




Urine examinations. 


Name. 




Name. 






Dates. 


Results. 


Dates. 


Results. 


Adam 


Sept. 13 
a 17 


+ 


Streitzel 


Sept. 12 
« 17 


+ 








+ 




« 19 


+ 




Oct. 5 


— - 




" 25 


— 




" 21 


+ 




Oct. 1 


+ 




" 28 


+ 




" 18 


+ 




" 30 


— 




" 20 


— 




Nov. 4 


— 




« 26 


~ 




" 18 
" 18 


+ 


Bier 


Sept. 7 


+ 




Oct. 8 


— » 




" 16 






" 15 


+ 




" 21 


+ 




" 21 


+ 




" 30 






" 30 
Nov 6 

" 22 
" 29 


+ 



+ indicates typhoid bacilli present; — , typhoid bacilli absent. 

Every suspicious growth was identified by the Russell double sugar 
medium and then by serum agglutination. The results in 3 of the 
12 cases thus examined are cited in Table XXI. 

We sought the explanation for the striking results shown in Table 
XXI. Keeping in mind the general laboratory experience that 
sterile cultures are often seen on solid media when growths occur in 
broth, we continued the above plan of separately examining every 
specimen voided by 5 patients, but this time cultures were made not 
only on Endo plates, but also in broth (from 1 to 2 cc. of urine). The 



A. L. GARBAT 



57 



TABLE XXI. 



Name. 


Urine examination. 


Name. 


Urine examination. 




Date.* 


Time. 


Result. 


Date. 


Time. 


Result. 






a.m. 








p.m. 






Sept. 13 


2 
p.m. 


— 


Trautman . . . 


Sept. 13 


2 
5 


+ 






4 


+ 






8 


+ 






7 


_l_ 
i 




" 14 


7 


+ 






10 


— 






10 


+ 






a.m. 








a.m. 






« 14 


11 


— 




" 15 


5 


+ 




" 15 


p.m. 

3 
9 

a.m. 
4 
8 

p.m. 
1 

3 

11 
p.m. 


+ 

+ 




" 16 


8 

P.m. 

2 

7 

11 

a.m. 

5 

- p.m. 
1 

5 


+ 

+ 
+ 

+ 

+ 
+ 




" 17 


9 

a.m. 


— 






8 
10 


+ 

+ 




" 18 


3 


+ 






11 

a.m. 


mmmm 




« 19 


12 

8 

a.m. 


— 




" 17 


5 
8 

p.m. 
2 


— 




" 20 


4 


+ 






6 
9 







" 22 


7 

a.m. 


+ 






10 
a.m. 


+ 




" 23 


3 


+ 




" 18 


6 


+ 




" 24 


4 


+ 






p.m. 






" 25 


1 


+ 






2 









6 


+ 






6 


+ 






p.m. 








9 









2 


+ 






11 









8 


+ 






a.m. 








11 


— 




" 19 


5 









a.m. 














" 26 


4 
6 


+ 

+ 














58 



TYPHOID CARRIERS AND TYPHOID IMMUNITY 



TABLE XXI— Concluded. 





Urine examination. 




Urine examination. 


Name. 




Name. 






Date. 


Time. 


Result. 


Date?. 


Time. 


Result. 






p.m. 








p.m. 






Sept. 13 


9 

a.m. 


+ 


Muza 


Sept. 19 


5 
8 


+ 




« 14 


2 


+ 






a.m. 








6 


+ 




" 20 


4 


+ 






P.m. 








p.m. 








4 


— 






4 


__ 






a.m. 








9 






" 15 


2 


— 












9 

p.m. 








a.m. 












" 21 


8 


+ 




" 16 


9 

a.m. 


+ 




" 22 


10 

4 


— 




« 17 


4 

p.m. 

5 


+ 






7 

P.m. 

2 








7 


-f 






5 


— 






a.m. 








8 


— 




" 18 


8 


+ 






a.m. 






« 19 


7 


+ 




" 23 


2 


— 






10 


+ 






5 


— 






£.m. 








7 


— 






1 


+ 














2 


+ 











results from 1 case are noted in Table XXII. The other 4 patients 
gave similar results. 

It was thus definitely proved that the use of Endo plates alone for 
the purpose of detecting typhoid bacilli in the urine is insufficient 
unless the number of bacteria happens to be excessive. The safe 
procedure is first to obtain a 24 hour growth in broth and then to 
make an Endo plate therefrom. 

The irregularity in the excretion of typhoid bacilli in the urine thus 
seemed to be explained as dependent upon the technique; i.e., the use 
of solid media only. On further study, however, it was soon found 
that there was an ac tual intermittency in the excretion of the typhoid 
bacilli. That is, certain specimens of urine were found absolutely 
sterile (also in broth), while others voided within several hours were 



A. L. GARBAT 



59 



full of typhoid bacteria. As examples, we may cite the following 
cases (Table XXIII). 

Thus it is surprising to find, for example, a urine (Schubert, Table 
XXIII) full of typhoid bacilli at 3 p.m., sterile 4 hours later, and 
full of typhoid bacilli again 3 hours later. It only definitely proves 
that excretion of typhoid bacteria in the urine follows an intermittent 
curve. 

TABLE XXLT. 



Name. 



Schubert. 



Date. 


Time. 


§ 
£-£ 

u 


a 
o 
to 

<n . 

2$ 

so 
— •- 
s-o 
U 




a.m. 


Sept. 27 


4 


+ 


+ 




9 


+ 


+ 




p.m. 








5 


+ 


+ 




8 


-f 


+ 




11 


+ 


+ 




a.m. 






" 28 


3 


+ 


+ 




6 


-f- 


+ 




p.m. 








2 


— 


+ 




6 


— 


+ 




10 


— 


+ 




a.m. 






" 29 


1 


— 


+ 



Name. 



Schubert 







a 
o 


Date. 


Time. 


-2J « 




a.m. 


Sept. 29 


2 


— 




6 


— 




8 


— 




«. 






12 


— 




p.m. 






4 


— 




9 


— 




a.m. 




" 30 


1 


+ 




8 


+ 




p.m. 






4 


+ 




11 


+ 



.a 

O 

hi 

60 
in . 

3-° 

u 



+ 
+ 



- + 

+ 
+ 

+ 
+ 

+ 
+ 



During the entire study, it was noted that although practically the 
same quantity of urine was used for plating, the intensity of the growth 
on the Endo plate varied greatly. A quantitative estimation of bacteria 
in the urine was therefore undertaken in order to determine the 
approximate curve of excretion in any one patient. A pour plate in 
agar was made from 0.05 to 0.5 cc. of every specimen voided, incubated 
for 24 hours, and the number of colonies counted. Control cultures 
of each urine were made on Endo plates and in broth in order to 
ascertain any contaminating organisms. Results are shown in Table 
XXIV. 



60 



TYPHOID CARRIERS AND TYPHOID IMMUNITY 









TABLE 


XXIH. 
















a 
o 


ja 








§ 


.S 








"2.2 


a 










I 


Name. 


Date. 


Time. 


3 o 
u 


5 

S3 •*•» 
±2 »* 


Name. 


Date. 


Time. 


8.8 
o 


2 

3 O 

o 






a.m. 






p.m. 






Oct. 1 


6 
10 


+ 
+ 


+ 
+ 




Oct. 1 


8 
a.m. 


+ 


+ 






p.m. 








" 2 


10 


+ 


+ 






3 


+ 


•f 






p.m. 










7 


— 


— 






1 


+ 


+ 






10 


+ 


+ 






4 


— 


— 






a.m. 










9 


+ 


+ 




« 2 


1 


+ 


+ 






a.m. 










6 


+ 


+ 




" 3 


5 


+ 


+ 






11 


+ 


+ 






p.m. 










p.m. 










2 

a.m. 


+ 


+ 






5 
10 


+ 


+ 

+ 




Sept. 27 


1 

p.m. 


+ 


+ 






a.m. 










3 


+ 


+ 




" 3 


3 


+ 


+ 






6 


+ 


+ 






7 


+ 


+ 






11 




— 






/>.»». 










a.m. 










3 


— 


— 




" 28 


6 


— 


+ 






8 


+ 


+ 






n. 










11 


+ 


+ 






12 


+ 


+ 






a.m. 










p.m. 








" 4 


2 


— 


+ 






2 


— 


+ 






8 


+ 


+ 






7 


— 


+ 




Sept. 29 


8 


+ 


+ 






a.m. 










11 


+ 


+ 




" 29 


2 


— 


+ 






p.m. 










7 


— 


+ 






4 


+ 


+ 






n. 










8 


+ 


+ 






12 


— 


+ 






a.m. 










p.m. 








" 30 


6 


— 


+ 






2 
6 


— 


+ 

+ 






3 


+ 


+ 




« 30 


6 


+ 


+ 






8 


+ 


+ 






9 


+ 


+ 






m. 










a.m. 










12 


— 


— 




Oct. 1 


7 


— 


— 






a.m. 










p.m. 








Oct. 1 


6 

n. 

12 


+ 


+ 
+ 






1 




+ 



1 1,000,000 
10,000,000 
9,000,000 
8,000,000 
7,000,000 
6,000,000 
5,000,000 
4,000,000 
3,000,000 
2,000,000 






& 1,000,000 



100,000 



u 
<d 

v- 
o 

$-, 
o 

6 

>g 50,000 



30,000 

10,000 

1,000 









o 
o 



CM 



o 



o 

+-• 
o 
Q 



O 
O 



m 



o 
o 



P- CO 






p m *o fr- co o> Q 






§ 

3 






£ 
Z 



A. L. GARBAT 



61 



TABLE XXIV. 



Name. 


Date. 


Time. 


Total No. of 
colonies per cc. 


Name. 


Date. 


Time. 


Total No. of 
colonies per cc. 






P.m. 








a.m. 




Schubert . . 


Oct. 1 


3 


60,800 


Schubert . . 


Oct. 8 


* 









7 







" 11 


* 









10 


6,260,000 




" 12 


* 









is. 






« 14 


* 









12 


80,000 






p.m. 






" 2 


a.m. 

6 

11 

p.m. 

5 

10 


25,100 
2,640,000 

2,400 
6,500 




" 15 

" 16 

" 17 

" 18 
« 19 


11 

a.m. 

8 
* 

* 

* 


232 

158 



500 




" 3 


3 

7 

p.m. 


520,000 
11,000 




" 20 


p.m. 

9 

a.m. 


300 






3 







" 21 


8 


400 






8 
11 


520,000 
2,240,000 




" 22 

" 23 
" 24 


* 
* 
* 









" 4 


2 

p.m. 


500,000 




" 25 
" 26 


* 
8 



3,400 






2 

8 


10,370,000 

288 




" 27 
" 28 


9 

8 


4,200 
2,000 






11 


3,200 




" 29 
" 30 


* 

* 








" 5 


4 

7 

p.m. 


1,440,000 
58,000 




" 31 

Nov. 1 

" 2 


* 
* 
* 











11 

a.m. 


20,800 




" 3 
" 4 


* 
* 








" 6 


5 


64 






a.m. 








p.m. 






" 5 


7 


200 






2 


1,200,000 




" 6 


* 









8 


40 




" 7 


* 









a.w. 






" 8 


* 







" 7 


1 







" 9 


* 









9 


4,300 




" 10 


* 









11 


15,600 











All specimens. 



Number of bacteria 



P 3 .>>• 



„->} 03 _<0 „0 ►_ 



£ 



Oct 1 


o 5 o < 


3 




6 i 


S000000S8S0 


3 p.m. 
7 .. 

10 « 
12m. 

Oct. 2 6a.ra. 

11 « 











— 60,800 














2,40 

' 6 


«?£,W« 


GO, 


ooo 






2,64-0,6 


' 6, 
00 


a 60,000 




5 p.m. 
10 " 


P9 ^z 














Oct. 3 3a.m. 

7 ,i 

3 p.m. 






*j/,ooo 








0,000 
0,000 


I 4 O.OOC 










8 " 

11 " 














Oct. 4 2 a.m. 
2 p.m. 


286 








500, 


000*-£Z- 








JO. 


370,000 




8 " 
11 ■• 
Oct. 5 4a.m. 
7 » 


a3fe* 
























1 SS.OOC 






-*1,440, 


OOO 










1 1 p.m. | 


■ — "~2®SOO 


















2p.m. 

8 « k 

Oct. 7 1a.m.* 


; # ■■ 










-/,20O,0 


OO 










■**-■ 1 










— 1 






















' — *>» 
9 " , 


-*^3C 























11 ■■ 






*-J5,60C 














































Oct. 9 


























Oct. 10 


























Oct. 11 


























Oct 12 


























Oct. 13 ' 


























Oct. 14 * 


























Oct. 15 11p.m. 


J232 
























Oct. 16 8am 


1 158 
























Oct. 17 ' 


























Oct. 18 


























Oct. 19 


J500 
























Oct. 20 9p.m. 


: \300 
























Oct 21 8a.m. 


y400 
























Oct. 22 < 




















































Oct. 24 


























Oct. 25 


^ 














1 








Oct. 26 8&m 


^^-»« 


->»3,4GK 






















Oct. 27 9 " 




U,2a 


1 






















^>^ 


** 2,000 






















Oct. 29 1 


^•"^ 
























Oct. 30 


























Oct. 31 


























Nov. 1 


























Nov 2 


























Nov. 3 


























Nov. 4 


\. 
























Nov. 5 7am. 


>2CC 
























Nov. 6 


























Nov. 7 


























Nov. 8 


























Nov. 9 


























Nov. 10 


l_ 




















\ 





62 



TYPHOID CARRIERS AND TYPHOID IMMUNITY 



It is interesting to note the marked changes; e.g., from 10,000,000 
colonies to 200 in the course of 6 hours. Graphically represented, 
these figures are even more striking. The presence of several sterile 
specimens among the positive ones should be noted (Chart 1). 



table xxv. 



Name. 


Date. 


Time. 


Total No. of 
colonies per cc. 


Name. 


Date. 


Time. 


Total No. of 
colonies per cc. 






p.m. 








p.m. 




Wietchel . . 


Sept. 30 


6 
9 


24,000,000 
6,720,000 


Wietchel . . 


Oct. 5 


11 

a.m. 









10 


28,000,000 




" 6 


8 







Oct. 1 


a.m. 

7 









P.m. 
2 


o 






p.m. 
1 
6 


1,920 
18,200,000 






3 

11 








" 2 


11 

a.m. 

7 

p.m. 

3 

7 

a.m. 


8,400,000 

64 

2,680,000 
3,600 




" 7 

u 9 

" 10 
" 11 
" 12 


7 
* 

* 

* 
* 

m. 











" 3 


7 

n. 







" 12 


12 

a.m. 


800 






12 


36,400,000 




" 13 


7 


1,200 






p.m. 






" 14 


* 









3 


122,000 




" 15 


* 









6 


11,600,000 




" 16 


* 









a.m. 






" 17 


* 







" 4 


7 


100 




" 18 


* 









p.m. 






" 19 


* 









9 


4,140 




" 20 


* 









a.m. 






" 21 


* 







" 5 


7 


216,000 











* All specimens. 

Another patient (Wietchel) in whom a quantitative determination 
was undertaken proved of interest because the estimate was begun 
just before the urine became negative. It is observed that when the 
excretion of the typhoid bacteria ceases, it does not necessarily do so 
by a gradual downward curve but by an abrupt intermittent fluctu- 
ating one (Table XXV). 



40,000,000 
35,000,000 
30, 000,000 
25,000,000 
2 0,000,000 
15,000,000 



rtJ 



fe 10,000,000 



o 






$000,000 



2 1,000,000 
500,000 
100,000 
60,000 
20,000 
15,000 
10.000 



1.000 









^ 














( 


^> 














< 


^ 










o 






Si- 










Q> 






ft 










or 

8 * 




i 


*3 










c> (tf 
















O* ^ 
















O . 
















Q> t 
















'V 1 
















<V 


CN 
















O 
















1 


Q 
















I 


Cf 
















I 


^ 
















1 


<\i 


















I c 


> 


8" 












f 




\ < 


et 


^0 
















! 


1 


5f 












J 




\ v 


H 
















U 


D" 


u 














\ 


r O 


II 














i 


0) 












£> 1 






CD 


1 










§ 






<u 


1 










^ 






c\2 


1 










8i 






t 






"s» 






to 






ft 


I 1 


< 


:> 












II 


1 


( 











- 




j 1 






N 














I 


( 


V 












I 1 


& 
















1 1 


£ 
















1 


o 
















1 


Sf 
















1 1 


^ 


















T 


^ / 


\ 












1 




^ / 










^ 


















i 


















/ 


<°A 














h 


\ 


N 




1 

I, 


■» » « — •- 


-« 



cdcdo t— — <<o *->r- co t- 



O 
CO 

in 



8 



(M 



O 
O 



6 qS r 

CO >~P- 
*^- cvicOiO 




6 






S5- 

<0 Ci-" 


c 

: v- 


CO 




^f 




lO 




to 


t- 


o 

o 




o 

o 




o 
o 




o 
o 


-K 

c 



Chart 2. Quantitative estimation 



Number of bacteria 





Sept. 30 6pm 
10 " 






Oct. 1 7am. 




1p.m. 
6 •■ 




11 » 
Oct. 2 7am. 




3p.m. 




7 .i 


n 

> 

■n 
H 


Oct. 3 7a.m. 

12 n 

3 p.m. 
6 « 


JO 


Oct. 4 7a.m. 




9 p.m. 




cr. 


Oct. 5 7am. 




11p.m. 


l 


Oct 6 8am. 

2 p.m. 

3 " 


o' 


11 " 


O 


Oct. 7 7 am 




10 « 
2 p.m. 


5" 


Oct. 8 8am 


5' 


Oct. 3 


(3 

5- 


Oct. 10 


o> 




2 


Oct. 11 


X, 


Oct. 12 12m. 


< 


Oct. 13 7arr 
Oct. 14 




Oct. 15 




Oct. 16 




Oct. 17 




Oct 18 




Oct. 19 




Oct. 20 




Oct 21 




A. L. GARBAT 63 

The fluctuations in this patient's excretion of bacteria were even 
greater than those in Chart 1. A drop from 36,000,000 to 100,000 
occurred within 3 hours. A graphic representation of this patient is 
seen in Chart 2. 

An especially instructive tabulation was made on a patient who for 
a time was considered a permanent urine typhoid carrier (Table 
XXVI). He continued with a marked excretion of typhoid bacteria 
in the urine for 6 weeks. Quantitative estimations were begun 19 
days after the onset of normal temperature and continued on almost 
every specimen voided for 5 weeks. As in the foregoing instance 
(Table XXV), there is no gradual downward curve in the number of 
bacteria when the urine is nearing the time of complete sterility but 
an intermittent fluctuating type of excretion. A graphic presentation 
of this patient's excretion is given in Chart 3. 

In these patients, all urines continued to be cultured for many 
days after the specimens were repeatedly sterile, and in all cases 
there were occasional urines which showed typhoid bacilli. In no 
instance was there a renewed excretion of typhoid bacteria for any 
length of time once the urine continued negative in every specimen 
for several days. 

To establish more conclusively this intermittent excretion of typhoid 
bacteria, 3 patients were asked to void every hour during the day and 
a quantitative estimation of each specimen was made separately. 
In this way multiplication of the bacteria in the bladder was avoided. 
Tables XXVII and XXVIII (Charts 4 and 5) tabulate the results 
of two such experiments. They show definitely that there is an 
actual fluctuation of the number of bacteria excreted in the different 
hourly specimens of urine. At the same time it appears as if the very 
high figures in the former charts are partly accounted for by a growth 
of the bacteria in the bladder urine. 

It is very important to note that there was a sterile specimen 
passed at 7 p.m. (Table XXVII), while the one before it (6 p.m.) and 
the one after it (8 p.m.) contained typhoid colonies. 

In doing one of these experiments, we luckily struck the last hour 
that the typhoid bacteria appeared in the patient's urine. As will be 
seen from Table XXVIII, all the urines passed at or before 3 p.m. 
contained numerous typhoid bacteria, while all the specimens after 



64 



TYPHOID CARRIERS AND TYPHOID IMMUNITY 



TABLE XXVI. 



Name. 


Date. 


Time. 


Total No. of 
colonies per cc. 


Name. 


Date. 


Time. 


Total No. of 
colonies per cc. 






p.m. 








a.m. 




Mueller 


Sept. 30 


8 


1,330,000 


Mueller. . . 


Oct. 7 


6 


2,980,000 






m. 






" 8 


10 


6,300,000 






12 









re. 








a.m. 








12 


2,000,000 




Oct. 1 


6 
p.m. 


150,000 






p.m. 
2 


1,280,000 






4 


5,860,000 






3 


1,400,000 






8 


2,160,000 






7 


141,000 






a.m. 








9 


1,260,000 




" 2 


10 


680,000 






a.m. 








p.m. 
1 

4 
9 


1,800,000 
o 




" 9 


2 
6 


1,920,000 
740,000 






1,050,000 






11 


456,000 






a.m. 








p.m. 






" 3 


5 

p.m. 


43,200,000 






3 
9 


1,740,000 
528,000 






2 


10,300,000 






10 


1,200,000 






9 


8,640,000 






a.m. 








a.m. 






" 10 


1 


60,000 




m 4 


9 


12,300,000 






6 









11 


6,400,000 






11 


10,400,000 






w. 








p.m. 








12 


15,800,000 






3 


8,000,000 






p.m. 








8 


1,400,000 






3 


2,600,000 






10 


980,000 






5 


8,400,000 






a.m. 








a.m. 






" 11 


1 


1,120,000 




" 5 


6 
11 


15,800,000 
10,000,000 






7 
p.m. 


1,320,000 


- 




p.m. 








2 


1,400,000 






4 


9,640,000 






5 


760,000 






5 


1,680,000 






8 


440,000 






8 


960,000 






a.m. 








w. 






" 12 


2 


1,540,000 






12 


8,600,000 






7 


600,000 






a.m. 








p.m. 






" 6 


11 

p.m. 

2 


740,000 
560,000 






2 
9 

a.m. 


1,200,000 
1,800,000 






3 


2,180,000 




" 13 


6 


2,420,000 






9 


1,380,000 











A. L. GARBAT 



65 



TABLE XXVI— Continued. 



Name. 


Date. 


Time. 


Total No. of 
colonies per cc. 


Name. 


Date. 


Time. 


Total No. of 
colonies per cc. 






p.m. 








a.m. 




Mueller 


Oct. 13 


4 


1,420,000 


Mueller . . . 


Oct. 20 


1 


840,000 






7 


1,960,000 






5 


520,000 






a.m. 








n. 






" 14 


3 
6 


1,620,000 
2,160,000 






12 

p.m. 


1,880,000 






11 


1,240,000 






3 


1,820,000 






p.m. 








7 


1,420,000 






7 


1,640,000 






9 


11,200 






11 


1,280,000 






11 


1,120 






a.jre. 






" 21 


6 


9,000 




" 15 


6 


1,420,000 






a.m. 








10 


1,260,000 




" 22 


9 


1,880,000 






p.m. 








p.m. 








1 


540,000 






1 


800,000 






4 


860,000 






2.30 


3,800 






8 


920,000 






6 


8,200 






a.m. 








9 


5,640 




" 16 


2 


760,000 






a.m. 








7 


1,280,000 




" 23 


4 


5,000 






11 


940,000 






8 


2,200 






p.m. 








n. 








6 


1,450,000 






12 


152,000 






a.m. 








p.m. 






" 17 


1 


750,000 






3 


52,600 






6 


900,000 






9 


40,000 






11 


1,240,000 




" 24 


a.m. 








p.m. 








6 


3,920 






9 


840,000 






8 


2,820 






a.m. 








10 


470,000 




" 18 


6 


750,000 






p.m. 




t . 




p.m. 








2 


94,000 






3 


330,000 






8 


218,000 






8 


1,060,000 






11 


300,000 






10 


510,000 




" 25 


a.m. 








a.m. 








5 


92,000 




" 19 


4 


720,000 






». 








6 


620,000 






12 


114,000 






p.m. 








p.m. 








1 


400,000 






2 


2,920 






7 


520,000 






4 


2,880 














9 


180,000 



66 



TYPHOID CARRIERS AND TYPHOID IMMUNITY 



TABLE XXVI— Concluded. 



Name. 


Date. 


Time. 


Total No. of 
colonies per cc. 


Name. 


Date. 


Time. 


Total No. of 
colonies per cc. 






a.m. 








p.m. 




Mueller .... 


Oct. 26 


1 


158,000 


Mueller . . . 


Oct. 28 


6 


300 






5 


240,000 






9 


50 






10.30 


124,000 






IB. 








p.m. 








12 


220 






6 


1,000 






a.m. 








a.m. 






" 29 


10 


240 




" 27 


1 


800,000 




" 30 


* 









7 


1,860 




" 31 


* 









11 


236,000 




Nov. 1 


* 









p.m. 






" 2 


* 









2 


470,000 




" 3 


* 









8 


166,000 




« 4 


* 









a.m. 






" 5 


* 







" 28 


7 


800 




" 6 


* 









10 


650 




« 7 


* 









n. 






" 8 


* 









12 


920 











All specimens. 



TABLE XXVII. 



Name. 


Date. 


Time. 


Specific gravity 
of urine. 


Total No. of 

typhoid colonies 

per cc. 






a. m. 






Streitzel 


Nov. 5 


9 
10 


1.022 
1.020 


27,000 




8,200 






11 


1.022 


1,250 






12 


1.022 


340 






p.m. 










1 


1.014 


5,130 






2 


1.016 


100 






3 


1.020 


380 






4 


1.016 


10 






5 


1.022 


220 






6 


1.026 


20 






7 


1.024 









8 


1.020 


170 






9 


1.020 


220 



45,000,C 
40,000,C 
35,000,C 
30,000,C 
25,000,C 



(6 

o 

(0 






20,000,( 



15,000,( 



10,000, 



5,000,rf 




^ PL <T> P_ 

c\i cot- <T>v<£> CD-^JiP) 


<0 Pp. 


iDCR^fOOcJcO 






CJ 




—> Cvi 


CO 


cm oj 


CM 


+-> -•-> 


-»-> 


O O 


o 


oo 


o 



CXVI). 



Number of bacteria 



Sept 30 8pra 
12m 

Oct.l 6am 
4p.m 




A. L. GARBAT 



67 



that showed no typhoid bacteria. From this particular patient, 
cultures were made separately of all urine specimens voided for the 

30,000 



25,000 



20.000 



J 0,000 



| 5,000 

8 

o" 1,000 
u 

0) 



600 



300 



150 



§ 












\ 












\ 












OCT \ 


** 


> 








\ <; 
\c 


^ / 

[ 1 


























4 


:> 


\ 






§ 

^ 




\ c 
\ C 














a. 





6 = 
en o 

O 



= d S == = = == = = 

^jCV3 — «CMO ^tf 4 O <D t~ CO Ol 



Chart 4. Hourly excretion of urine (Table XXVII). 



16 days after that and not one of them showed typhoid bacteria. 
Such an abrupt and permanent cessation of the typhoid bacilluria is 
unusual. 



TABLE XXVIII. 



Name. 


Date. 


Time. 


Acidity of urine in 

terms of cc. 0.1 N 

NaOH per 100 cc. 

of urine. 


Total No. colonies 
per cc. 






a. m. 


cc. 




Streitzel. 


Nov. 16 


8 
9 


45 

26 


8,000 




12,000 






10 


21 


14,200 






11 


24 


8,400 






12 


26 


16,000 






p.m. 










1 


17 


880 






2 


65 


8,400 






3 


26 


9,600 






4 


45 









5 


20 









6 


66 









7 


54 






(0 



1 



17,500 



15,000 



12,500 



10.000 



7,500 



5,000 



1,000 




I 

Chart 5. Hourly excretion of urine (Table XXVIII). 

68 



A. L. GARBAT 69 

All experiments thus far described prove definitely that culturing 
a single specimen of urine for the presence of typhoid bacteria and 
concluding from a negative result that typhoid bacilluria does not 
exist, is absolutely erroneous. Even two consecutive examinations 
at intervals of a fixed number of days would surely miss a great per- 
centage of carriers. The Army rule of not considering a patient free 
of bacteria until 3 consecutive urine cultures at intervals of 6 days are 
proved negative, appears very stringent. To our great surprise, even 
this is not a dependable rule if complete freedom from bacteria is 
sought. This was determined in one of the patients in whom cultures 
were made separately of every specimen voided (Schubert). The 
3 routine urines which were cultured at intervals of 6 days hap- 
pened to be sterile, whereas other specimens passed within several 
hours on the same days were positive; furthermore, isolated urine 
specimens continued to show typhoid bacilli for 2 weeks after the 
routine third consecutive negative urine. 

The possibility of erroneous conclusion with the Army rule as 
guide, was proven in another way. 25 patients were selected who 
were apparently free of typhoid bacteria. A sterile 24 hour specimen 
of urine was collected from each patient. Every time that the 
patient voided, a sample (the last part) was passed into a large sterile 
bottle. From this mixed 24 hour specimen, 15 to 20 cc. were cultured 
in a broth flask and 1 cc. was spread on an Endo plate. We found 
that 5 out of these 25 cases (20 per cent) showed a positive typhoid 
growth. All of these patients had shown typhoid bacteria in the 
urine previously, during early convalescence. As will be seen from 
Table XXIX there was an interval of 5, 6, 8, 9, and 11 days respec- 
tively from the time of the last or third consecutive negative urine 
until the time of the positive 24 hour specimen. In 3 of these 5 
patients, the bacteria in the 24 hour specimen were so numerous that 
a growth was obtained even on the Endo plate. In the other 2, the 
growth was obtained only in the broth flasks. Undoubtedly these 5 
patients were excreting typhoid bacteria in the urine intermittently 
during the time of the 3 consecutive negative urines and even after 
that, although the urines had been considered no longer infectious. 



70 



TYPHOID CARRIERS AND TYPHOID IMMUNITY 



TABLE XXLX. 



Name. 


No. of previous positive 
urine cultures during 
early convalescence. 


4> 

•S 

3 
V 
K» 

tn 
O 

O. 

tn 

•S3 

SI 

Q 


a 
*c 

3 

1 
oi 

V 

C 

W . 

•"" ■ Uc 

o3 

■*-> 3 

ft 


■ c 

*w 

a 

en 

>- 
3 
o 
& 

a 
•8"g 

Q 


I 

03 O) 

o'<-> 

Is 

— . 3 

a o 
ft A 
"So-* 
fw 

O 


Broth culture from 24 
hour specimen. 


Interval between last iso- 
lated negative urine cul- 
ture and the positive 24 
hour specimen. 
















days 


Buschendorf. 


3 


Sept. 23 


Oct. 7 


Oct. 15 


+ 


+ + 


8 


Ackerman.. . 


2 


« 11 


" 7 


" 15 


Few staphy- 
lococci. 


Many staphylococci. 






2 


" 11 


" 1 


" 7 


« u 


None. 




Oestrick 


2 


" 10 


« 14 


" . 7 


None. 


Few staphylococci. 




Pfefferman. . 


2 


" 14 


Sept. 26 


« 7 


+ + 


++ 


11 


Karpinsky . . 


2 


" 10 


Oct. 3 


« 7 


None. 


None. 




Koszuta 


2 


" 10 


Sept. 30 


" 7 


Staphylo- 
cocci. 


Bacilli proteus. 




Bier 


2 


" 21 


Oct. 12 


" 15 


None. 


None. 




Schlange... . 


2 


" 17 


" 15 


" 18 




Staphylococci. 




Griechen 


2 


« 19 


" 7 


" 15 




Few staphylococci. 






3 


" 25 


" 14 


" 18 




Colon bacilli. 




Majorowski 


2 


" 7 


" 5 


" 7 




Bacilli proteus. 




Gesinski .... 


2 


" 20 


" 9 


" 15 




+ + 


6 


Kellerman . . 


3 


" 24 


" 13 


" 15 




None. 




Hermans .... 


2 


" 13 


" 9 


" 13 




Few staphylococci. 






1 


" 25 


" 5 


" 15 




it ti 




Poelman. . . . 


2 


" 25 


« 14 


" 19 


++ 


+ + 


5 


Dich 


3 


" 21 


" 10 


« 15 


None. 


Colon bacilli. 






3 


" 25 


« 14 


" 18 




Staphylococci. 




Jannssen.. . . 


4 


" 25 


« 14 


" 18 




it 




Miller 


2 


« 9 


" 7 


" 7 




None. 




Mannoff 


3 


" 23 


« 14 


" 23 




+ 


9 


Hollwege . , . 


3 


Oct. 7 


Nov. 3 


Nov. 5 




None. 






5 


« 14 


" 2 


" 5 




tt 




Gutte 


3 


Sept. 14 


" 2 


" 5 




a 





+ indicates typhoid bacilli present; + + , heavy growth of typhoid bacilli; 
none, sterile. 



Accurate Method for Detecting Typhoid Bacilli in Urine. 

The objection to using a 24 hour specimen of urine for culturing 
purposes is the possibility of secondary infection or contamination. 



A. L. GARB AT 71 

Of the original Endo plates made from the twenty-five 24 hour 
specimens, 19 were sterile, 3 had typhoid bacteria, and 3 showed 
staphylococci. Of the broth cultures 8 were sterile, 8 showed staphy- 
lococci, 2 showed colon bacilli, 2 showed Bacillus proteus, and 5 
showed typhoid bacilli. The typhoid bacteria were in pure culture. 
The liability of contamination should not, therefore, be raised as an 
objection against culturing 24 hour specimens of urine. 

When liquid media are employed, the quantity of urine used for 
culturing purposes is important. Cultures were made in broth from 
varying quantities of the same urines and, where the bacteria in the 
urine were few in number, cultures were positive only when larger 
quantities of urine were added to the broth. In the cultures of the 
24 hour specimens of urine, 15 to 20 cc. of urine were added to 100 
cc. of broth. This quantity has a wide margin of safety. 

All the observations collected in this study leave no doubt that 
an accurate result for determining the presence of typhoid bacteria in 
the urine is possible only from a sample of a 24 hour specimen of urine 
which should be allowed to grow 24 hours in broth and then plated. 
The author is certain that were examinations made in this manner, 
it would be unnecessary to have more than 2 consecutive negative 
cultures before a patient might be considered free of typhoid bacteria 
in the urine. Furthermore, such cultures would not require 6 day 
intervals, but could be made at intervals of only 1 day or even on 
successive days. If 2 such negative 24 hour specimens are obtained, it 
is safe to assume that typhoid bacilluria no longer exists ; for we know 
from our observations that if typhoid bacteria are absent from every 
specimen of urine for several days, they are absent for good and do not 
recur, except possibly in an isolated specimen which would escape 
detection anyhow. Certain it is that urines examined at random 
intervals of 6 days, for example, will not detect all typhoid convalescents 
who are still carriers. When it is realized that some urines contain 
as many as 43,000,000 bacteria per cc, the great danger of discharging 
a patient with bacteria in the urine is evident. The above, accurate, 
even though more laborious method, is therefore indicated. 



72 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

B. Character or Urine; Origin and Frequency or Carriers. 

Importance of Typhoid Urine Carriers. 

While all writers lay sufficient stress upon the feces as a source 
for the spread of typhoid fever, the importance of the urine is usually 
underestimated. Even in a very recent and official publication (56) 
it is stated, "The feces of the patients suffering from typhoid is the 
most important means of contagion, " and little reference is made to 
the urine. Simon (57) in his excellent book on "Human Infection 
Carriers" hardly mentions the infections by the urine. At the same 
time, typhoid epidemics have been traced to urine carriers. Beck 
and Ohlmuller (58) report such an epidemic which involved 6.7 per 
cent of the entire population of Detmold in 1904. The epidemic was 
traced to a water supply of the city. The working men constantly 
engaged at work at this source were examined and one was found to be 
a urine carrier. He had had typhoid fever 3 months previously. The 
bacilli were also found in the soil near the well and were traced to a 
latrine made of earth which was used by these working men. 

The earliest cases of typhoid bacilli in the urine were reported about 
the same time by Rovsing (59), Houston (60), Young (61), and Brown 
(62). It is interesting to observe that the carrier problem was not 
clearly understood, as Brown at that time explained the presence of 
the numerous typhoid bacilli in the urine by a contamination from the 
outside, presumably by catheterization, although the woman had had 
typhoid fever 35 years previously. 

From the studies reported by the writer in the previous paper, it 
seems certain that typhoid patients are very often discharged with 
typhoid bacilli still in their urine. Because of the frequency with 
which the urine is voided, the myriads of organisms that it may contain, 
its relatively inoffensive character, and the consequent indifference to 
the place of its disposition by ignorant and careless nurses and con- 
valescents, it becomes as potent a factor, if not a more potent one than 
the feces in the spread of the disease. 

The percentage of typhoid convalescents who have typhoid bacil- 
luria(49per cent) is greater than the percentage of patients who have 
bacilli in the feces (39 per cent). Then too, the actual number of 
bacteria is far greater in the urine than in the stool. The greatest 



A. L. GARBAT 



73 



number found in our series of patients was 43 million per cc. Pet- 
ruschky (63) reports a urine in which there were 170 million bacteria 
per cc, and Gwyn (64) reports one in which there were 500 million 
per cc. 

The urines containing typhoid bacteria were especially studied with 
a view to ascertaining whether any relationship could be discovered 
between the existence or the degree of the bacilluria and any of the 
chemical properties of the urines. 

Chemical Properties of Urines Containing Typhoid Bacilli. 

(a) It was found that the number of bacteria had no bearing what- 
ever upon the specific gravity. In Table XXVII (Streitzel), for 
example, it is noted that a urine with a specific gravity of 1.014 con- 
tained 5,130 bacteria, while a urine with a specific gravity of 1.024 
was sterile. Other examples of such lack of relationship are cited in 
Table XXX. These specimens are all from the same patient passed 
at different times. 

TABLE XXX. 



No. of bacteria per cc. 


Specific gravity of urine. 


No. of bacteria per cc. 


Specific gravity of urine. 


680,000 


1.018 


330,000 


1.020 


1,800,000 


1.014 


1,060,000 


1.022 





1.014 


500,000 


1.028 


1,050,000 


1.020 


720,000 


1.010 


43,000,000 


1.022 


620,000 


1.018 



(b) The acidity of the urines was examined for a possible explana- 
tion of the great variations in the number of bacteria. The acidity 
was roughly estimated by titrating the urines with decinormal sodium 
hydroxide solution with phenolphthalein as indicator. No relation- 
ship between acidity and typhoid bacilluria or the number of bacteria 
could be determined (Table XXVIII). 

(c) The turbidity of the urine in relation to the number of typhoid 
bacteria was also studied. If a urine was turbid for no apparent 
cause other than the bacteriuria, that specimen usually contained 
more than 4,000,000 bacteria. At the same time it seemed very 
difficult to attribute the turbidity entirely to the bacilluria because 



V 



74 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

there were very many absolutely clear urines with even greater 
numbers of bacteria. One urine had 32,000,000 bacteria per cc. and 
was clear. Thus, no absolute relationship between turbidity and 
bacilluria could be offered. 

(d) The association between albuminuria and bacilluria was of 
special interest. The author cannot agree with Besson (65) or with 
Wood (66) that typhoid bacteria are present only when a consider- 
able quantity of albumin is passing through the kidneys. 

While the exact percentage has not been estimated, a great num- 
ber of specimens that had 10 to 20 million bacteria per cc. evidenced 
no albumin whatever. There is no doubt that bacilluria can exist 
without albuminuria. A consideration of the reverse possibility, 
namely, whether albuminuria necessarily implies the presence of 
bacilluria, would lead to erroneous conclusions, for there are very few 
typhoid cases which do not at some time or other during the course 
of the disease show albuminuria. The synchronous appearance of 
bacilluria and albuminuria is a coincidence as often as it is a matter of 
dependence. Sharp lines should be drawn between albuminuria and 
nephritis. True lasting nephritis (not merely toxic or febrile albumi- 
nuria) was found in only 2.5 per cent of our typhoid cases (4 out of 
164) and all of them showed typhoid bacilli in the urine. Vice versa, 
of the 49 per cent of patients who presented a typhoid bacilluria, only 
5 per cent showed the picture of a true nephritis. 

As to the frequency of typhoid bacteria in the urine, it is interesting 
to note the wide variations reported. Petruschky (63) found bacilluria 
in 6 per cent of his 50 cases; Horton-Smith (67), in 28 per cent of his 
39 cases; Schuder (68), in 23 per cent of his 22 cases; Cole (69), in 35 
per cent of his 49 cases; Richardson (70) in a review of the literature 
from 1887 to 1903 states that 30 observers had made bacteriologic 
investigations of the urines in 1,291 cases of typhoid fever and had 
detected bacilluria in 21.5 per cent of the cases. Osier (71) gives the 
percentage as 20 to 25. 

These differences in statistics are undoubtedly explained by the 
varied laboratory technique employed, and the frequency of the 
individual urine cultures. 

Of our 164 patients there were 80, or 49 per cent, who showed bacil- 
luria at some time during convalescence. The duration of the bacil- 



A. L. GARB AT 



75 



luria is shown in Table XXXI; the number of weeks after normal 
temperature that the bacteria continued in the urine is also designated. 
Thus, it is seen that 11 cases (13.7 per cent of all positive cases or 
6.7 per cent of all typhoid cases) remained positive for longer than 1 
month after normal temperature, and 2 cases (2.5 per cent of all 
positive cases or 1.2 per cent of all typhoid cases) were positive for 
longer than 2 months. No patients in our series remained carriers for 
longer than 3 months. 

TABLE XXXI. 



No. of cases. 


Per cent of all 
positive cases. 


Per cent of all 
typhoid cases. 


Duration of # 
positive condition. 








weeks 


17 


21.2 


10.3 


1 


34 


42.5 


20.7 


2 


12 


15.0 


7,5 


3 


6 


7.5 


3.7 


4 


2 


2.5 


1.2 


5 


2 


2.5 


1.2 


6 


2 


2.5 


1.2 


7 


3 


3.7 


1.8 


8 


1 


1.2 


0.6 


9 


1 


1.2 


0.6 


11 



TABLE XXXII. 



No. of 
cases examined. 


Time of examination 

after 
normal temperature. 


No. of cases 
positive. 


Per cent of cases 
positive. 


No. of cases 
negative. 




week 








127 


1st 


80 


63 


47 


145 


2nd 


63 


44 


82 


162 


3rd 


29 


18 


133 


164 


4th 


17 


10 


147 



A tabulation was made of the number of positive and negative cases 
occurring at various fixed intervals after normal temperature (Table 
XXXII). 

From Table XXXII it may be inferred that one may delay culturing 
the urine for bacteria until the second week of convalescence, be- 
cause in almost two-thirds of the cases, typhoid bacilli will be found 
during the first week after normal temperature. On the other hand, 
we had 8 patients in whom the urine became permanently nega- 



76 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

tive starting 3 to 10 days before the temperature had come down to 
normal. 

From Table XXXII it is also noticed that our original figure of 
80 cases of bacilluria out of a total of 164, or 49 per cent, would 
have been as high as 63 per cent had we been able to examine all of 
our cases during the 1st week after normal temperature. Owing to 
the stress of work, in 37 patients the first culture of the urine was 
made only in the 2nd to the 4th week after normal temperature. 

In 18 cases during the 2nd week after normal temperature. 
« iy a u « 3rd « « a t( 

ie 2 " " " 4th " " " " 

There are some patients in whom the bacilluria disappears with the 
onset of normal temperature and our investigations covered only 
the period of convalescence; i.e., after normal temperature had set in. 

The author has considered the possibility that practically every 
patient has typhoid bacteria escaping in the urine at some time or 
other during the disease or convalescence. This does not seem un- 
reasonable in view of the fact that typhoid bacteria circulate in the 
blood of every patient, and therefore some of these bacteria may 
escape through the glomeruli which have been exposed to toxic action 
for a shorter or longer period. This assumption can readily be 
investigated at a future occasion. 

Source and Origin of Typhoid Bacilluria. 

The source and origin of the typhoid bacilluria is not a simple 
problem for solution. No one explanation can be satisfactorily 
offered for all instances. Thus, it is erroneous to assume, as does 
Horton-Smith (67, 75), that in most cases stray bacilli find their way 
from the blood and through the kidney into the bladder and that it is 
here that the bacilli grow and multiply. This theory will account 
for only those cases in which the bladder is not entirely emptied at 
micturition, as occurs normally in many women or in men with 
prostatic hypertrophy or diverticula of the bladder. In these patients 
the retained urine remains to infect subsequent secretions of the 
kidney. The present writer is of the opinion that the bladder origin 
for typhoid bacilluria holds true only in a minority of patients and 



A. L. GARBAT 77 

that in by far the greater majority of cases the bacteria come from the 
urinary tract above the bladder. The author's studies (see Section 
V, A) which showed the variations in the number of bacteria of the 
different specimens and even the complete sterility of some, speak in 
favor of this view. If the bacteria were present in the bladder alone, 
one would expect them to be in the urine constantly and in approxi- 
mately the same quantity, although it cannot be denied that bacteria 
may multiply in the bladder. The experiments in which hourly 
specimens were examined eliminated the factor of the bacterial 
growth in the bladder and proved that the urine as it comes down 
from the kidney already contains different quantities of bacteria at 
different times. Furthermore, in two of our cases the ureters were 
catheterized and typhoid bacilli were found in the urine obtained 
only from the left side, the urine from the right side was sterile and 
the washings from the bladder proved sterile also. All these findings 
convinced the writer that in the usual typhoid bacilluria the urine 
already contains the typhoid bacilli before it reaches the bladder. 

When we attempt to answer the question as to how the bacteria 
get into the urine, we are confronted with just as difficult a question. 

From the standpoint of pathological anatomy, several types of 
lesions have been found in the kidneys of urine carriers which account 
for the presence of the typhoid bacilli in the urine. 

1. Multiple Focal Abscesses of the Kidney or Hydronephrosis. — Al- 
though this condition is not frequent, undoubted examples have been 
reported (Greaves (72), Meyer and Ahreiner (73)). In the case 
reported by Lieutenant-Colonel Nichols (41), a urine carrier condition 
which had continued for 6 years was due to a cystic kidney and was 
cured by nephrectomy. A pure culture of typhoid bacilli was isolated 
from the abscesses. 

2. Acute Nephritis. — The typhoid bacilli, like any other of the 
infectious bacteria, may cause a focal localization of the infection in 
the kidneys, resulting in an acute nephritis and subsequent escape of 
bacteria into the urine. 

Both of these conditions are comparatively rare in proportion to 
the frequency with which typhoid bacilluria occurs. Such marked 
anatomical changes probably account for some types of the more 
chronic urine carriers. The more transient bacillurias, however, 



78 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

which occur during the acute disease or convalescence cannot be 
explained on this basis. For these cases, a pathological condition 
must be found which is of a more general type and one which can 
proceed more readily to healing and disappearance of the bacilluria. 
Such a lesion is offered by the areas of focal necroses which take place 
in the kidneys as they do in the liver and spleen. 

3. Areas of Focal Necroses. — When one remembers that bacterial 
emboli are of frequent pathological occurrence during typhoid fever, 
the cause of these areas of focal necroses is evident. Cagnetto and 
Zancan (74) have shown that in most cases of typhoid fever, inflam- 
matory foci (so called "lymphomata") with focal necroses or even 
minute abscesses are found in the kidneys. These foci may act as 
vegetation depots for the typhoid bacilli from which the bacteria 
make their way into the adjacent urinary tubules. 

These three hypotheses imply a pathological destructive proc- 
ess of the kidneys which can be made out macroscopically or micro- 
scopically. On the other hand, the view may be advanced that the 
passage of the bacilli into the urine is merely a filtering process. 

4. Filtering Process. — Since typhoid organisms invade the blood 
stream in probably every case of typhoid fever, it is possible that some 
bacilli may find their way through the glomeruli into the urine. The 
glomerular structure and function may be rendered of lowered re- 
sistance by the bacteria themselves or by the effects of their toxins 
and thus allow the escape of some bacteria. That the kidney may 
possess the function of filtration, has not been definitely accepted. 
Granted that it does, one should expect to find the typhoid organisms 
in the urine at the time when the bacteremia is at its height. This 
is contrary to the actual state of affairs, because the bacilluria usually 
starts at a time when the bacteremia no longer exists. Nevertheless, 
the writer has several times observed instances in which a former 
negative urine would begin to show typhoid bacteria with the onset 
of a relapse. 

Thus it is seen that no one cause can be given for all cases of 
typhoid bacilli in the urine. The combination of the filtration process 
and the destructive process in the form of the areas of focal necroses 
will probably explain most of the transient bacillurias occurring during 
convalescence. 






A. L. GARBAT 79 

The mechanism whereby the bacteria escape into the urine being 
granted, this does not, however, by itself account for the marked 
variations in the number of bacteria in the different specimens and 
the complete sterility of some. Horton-Smith (67, 75) answers this 
question by the varying growth of the bacteria in the bladder. For 
reasons previously quoted we cannot agree with this assumption, but 
believe that when the urine reaches the bladder, it already contains 
different quantities of bacteria at different times. Retention of the 
urine in the bladder with subsequent growth of bacteria therein will 
only accentuate the already existing differences. The writer is of the 
opinion that it is an infection in the pelvis of the kidney or its numer- 
ous calyces which accounts for these variations in number. 

5. Injection in the Pelvis of the Kidney. — The pelvis bears the 
same relationship to the kidney that the gall bladder does to the liver. 
The bacteria may lodge in some calyces and not in others or some of 
the calyces may be infected more than others. The difference in the 
degree of bacilluria at different times will therefore be dependent upon 
which calyces are flushed out at a particular time and how com- 
pletely this is done. 

Furthermore, it is possible that the pelvis of the kidney does not 
completely empty at all times. The bacteria may be retained in 
some dependent portion thereof and grow there until the next occasion 
when the pelvis is completely flushed out, resulting in a shower of 
bacteria in the urine. 

One cannot designate this condition as pyelitis any more than one 
can designate the gall bladder condition in some chronic bile carriers 
as cholecystitis. In neither instance does the microscopical examina- 
tion of the urine or bile, respectively, necessarily show inflammatory 
evidences. The pelvis acts as a storehouse for the kidney in the 
same way that the gall bladder does for the liver. In the pelvis of 
the kidney, the bacteria do not multiply as readily as in the gall 
bladder or for as long a time: first, because the outlet into the bladder 
by means of the ureter is freer than the outlet into the intestines by 
means of the common bile duct; second, in the case of the urine, 
there is a more continuous stream and consequently a more frequent 
flushing than there is with the bile; and third, bile is a better medium 



80 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

for the growth of typhoid bacilli than urine. These differences 
probably account for the higher percentage of chronic or persistent 
gall bladder carriers than urine carriers. 

Classification of Urine Carriers. 

In the same comparative light one may propose a classification of 
urine carriers into kidney carriers, pelvic carriers, bladder carriers, or 
various combinations of these; just as we have classified liver carriers, 
gall bladder carriers, and intestinal carriers, or their combinations. 

While we have offered sufficient clinical and laboratory evidences 
in proof of the different bile carrier types, the classification of urine 
carriers is given only as a working basis for further substantiation and 
complete proof. 

That pure kidney carriers exist, can be and has been very readily 
demonstrated by ureteral catheterization where typhoid bacilli are 
obtained from one side only. Complete removal of the infected 
kidney clears up the carrier state. In these patients the involved 
organ usually shows marked destructive lesions, as multiple abscesses 
or hydronephrosis (case of Lieutenant-Colonel Nichols (41)). Even 
in the transient bacillurias, the kidney alone may be the organ ac- 
countable for the carrier condition. In 2 cases of our series, bladder 
washings were sterile, while typhoid bacilli were obtained from the 
left ureter only. These patients remained carriers for 5 and 6 weeks 
respectively but then cleared up. 

That pure bladder carriers may exist, with no bacteria in specimens 
obtained by catheterization of the ureters is also known. Women 
are more predisposed to this type on account of their incomplete 
emptying of the bladder. Originally, the bacteria enter the bladder 
probably by way of the kidneys but continue to grow in the retained 
bladder urine even after the original process in the kidneys has 
cleared up. This type of carrier should be readily amenable to local 
treatment. A bladder carrier of a somewhat different type is rep- 
resented by the cases of typhoid cystitis, although pure typhoid 
cystitis is not very frequent. In our entire series of 164 patients, 
there was only 1 case of true cystitis. The patient persisted with 
typhoid bacteria in the urine for over 2 months but then cleared up 



A. L. GARBAT 81 

entirely without any local treatment. Naturally, combinations of 
the kidney and bladder types are to be readily expected, because of 
the ease with which extension of the infection either by the descending 
or ascending route may take place. 

Pelvic carriers are as yet entirely problematical. No evidence can 
be offered as proof of their existence unassociated with either bladder 
or kidney involvement. 

Omission should not be made of the suggestion offered by Pick 
(76) that in some urinary carriers the bacilli lie in nests situated in 
recesses of the urinary tract; e.g., the urethral ducts, prostatic ampullae, 
or vesiculae seminales. Pick examined these organs in 32 autopsies 
of typhoid cases and in 2 instances discovered a suppurative sperma- 
tocystitis and prostatitis due only to Bacillus typhosus. Such 
types of chronic carriers are probably exceptional. 

Many of the phases of the urine carrier problem have not passed 
out of the hypothetical or experimental stage. Detailed analyses 
have been given of some of the facts that are known, and some of the 
questions must still be investigated in order that we may change our 
old ideas and stimulate new ones in the consideration of this very 
important condition. 



VI. THE COMPLEMENT FIXATION TEST FOR TYPHOID FEVER. 
STATISTICAL, CLINICAL, AND EXPERIMENTAL STUDIES. 

Complement Fixation Test during Typhoid Convalescence. 

Several years ago, the author proposed the complement fixation 
test as an additional laboratory aid for establishing the diagnosis of 
typhoid fever (77). It was then shown that practically all patients 
with typhoid fever develop complement fixation bodies sooner or later 
during the course of the infection. After further study (78) the 
writer found that people who had been inoculated against typhoid 
fever with the usual 3 antityphoid vaccine inoculations (Rawling 
strain) gave a positive complement fixation test only exceptionally and 
for a very short time. This reaction therefore becomes of especial 
importance as a differential diagnostic aid in patients who are sus- 
pected of having typhoid fever, and give a positive Widal test due to 
previous immunization, but in whom no typhoid bacteria can be 
found in the blood or excretions. Felke (79) from a similar study 
arrived at a similar conclusion. Hage and Korff-Petersen (80) agreed 
in principle to this differentiation but found that a small percentage 
of their inoculated persons gave complement fixation for 2 weeks after 
inoculation but only exceptionally after 2 months. 

The author's report published in 1914 (77) included fixation tests 
in patients during the active stage of the illness; but no systematic 
report exists in the literature referable to the value of the complement 
fixation reaction as a diagnostic test during typhoid convalescence, 
or months after the infection. The present paper includes such tests 
made on 160 patients. The stress of other work did not permit of 
testing the bloods sooner than 5 weeks after normal temperature. 
Table XXXIII shows the results of the examinations then made. 

It is noted that as high as 54 to 57 per cent of patients still give a 
positive complement fixation test 4 months after the active stage of 
typhoid fever, and in two-thirds of these the reaction is very strong 

(++ + +). 

82 



A. L. GARB AT 



83 



Through the interest of Colonel Russell, samples of blood from 
these patients (who were then at the Prisoners War Barracks at 
Fort Oglethorpe), were sent to U. S. A. General Hospital No.12 
several months later and the results of the second survey are shown 
in Table XXXIV. 

From a review of these two tabulations, it is evident that in about 
30 per cent of typhoid patients the complement fixation bodies dis- 
appear from the blood by the 2nd month after the onset of normal 



TABLE XXXHI. 



Time of examination after normal 


No. of 

cases 
exam- 
ined. 


No. of 
cases 
posi- 
tive. 


Degree of positive. 


Per cent 
of posi- 


temperature. 


++-H- 


+++ 


++ 


+ 


tive. 


2nd month (5, 6, 7, 8 weeks) 

3rd month (9, 10, 11, 12 weeks) .... 
4th month (13, 14, 15 weeks) 


22 

114 

14 


16 
67 

8 


13 
43 

5 


1 

5 



1 
9 



1 

10 

3 


72.7 
54.0 
57.0 


Total 


150 


91 


61 


6 


10 


14 


60.0 







TABLE XXXIV. 



Time of examination 
after normal temperature. 


No. of 

cases 
exam- 
ined. 


No. of 
cases 
posi- 
tive. 


Degree of positive. 


Per cent 
of . 


++++ 


+++ 


++ 


+ 


posi- 
tive. 


5th month (17, 18, 19, 20 weeks). . . 
6th month (21, 22, 23, 24 weeks). . . 


41 
119 


24 
49 


9 

20 


7 
7 


4 
12 


4 
10 


58.0 
41.0 


Total 


160 


73 


29 


14 


16 


14 


45.0 







temperature. During the 3rd, 4th, and 5th months after con- 
valescence, an additional 10 to 15 per cent of the patients lose this re- 
action. At the end of a half year 40 per cent of patients still show a 
positive complement fixation test. 

40 cases which were positive at the 2nd examination, were re- 
examined 2 to 3 months later. Only 2 reactions became negative; 
38 continued positive. The detailed results are shown in Table 
XXXV. 



84 



TYPHOID CARRIERS AND TYPHOID IMMUNITY 



These findings brought up the question why the complement 
fixation antibodies persisted in some patients long after convalescence, 
while in others they disappeared soon after or even before the onset 
of normal temperature. 

An analysis of our cases was therefore made from a clinical stand- 
point in order to determine any factors which might possibly account 
for these variations. 

TABLE XXXV. 



No. of cases 


Reaction at 2nd 
examination. 


Reaction at 3rd 
examination. 


3rd examination. 


in each group. 


No. of cases. 


Interval af te r nor- 
mal temperature. 










months 










[1 


6 


10 


+ + + + 


+ + + + 


' 


6 

2 

1; 


7 
8 
9 
6 


5 


+ + + + 


+ + + 


' 


: 


7 
8 


1 


+ + + + 


— 




7 










r 3 


6 


5 
3 


+ + + 
+ + + 


+ + + 


< 

< 


1 
2 


7 
8 
7 
8 


9 


+ + 


+ + 


{t 


7 
8 


1 


+ + 


+ 


I 5 


7 


5 


+ 


+ 


{! 


7 
8 


1 


+ 


— 




7 



Factors Accounting for the Persistence of a Positive Test. 

1. Blood Culture Findings. — It is well known that in animals anti- 
body formation is usually most rapid and marked when the intra- 
venous method of immunization is employed. It was therefore con- 
sidered probable that patients with a persistent positive blood culture 
would be more likely to continue with a positive complement fixation 
test. 



A. L. GARBAT 85 

It was found that out of 38 cases which had a positive blood culture 
only 24, or 63 per cent, showed a positive complement fixation test. This lasted 
in: 

3 patients for 3 months after normal temperature. 



2 


« 4 


t* 


n 


« 


8 


" 5 


tt 


u 


tt 


1 patient 


" 6 


u 


u 


tt 



Vice versa, of the 83 patients who had a negative complement fixation test during 
the second or third month of convalescence, 14, or 16 per cent, had shown a positive 
blood culture during the acute stage of the disease. 

It is evident that one cannot consider a positive blood culture as 
the indicator of a future persisting complement fixation test. Most 
or even all typhoid cases have a bacteremia during the early days of the 
infection, but we detect the bacteria in the blood of some and not of 
others because in some the bacteria are probably in greater numbers 
in the free circulation or they remain there for a longer time. A 
negative blood culture only signifies that the blood was examined at 
an inopportune time. 

2. Length of the Fever Course. — It was felt that the longer the fever 
existed, the more likely was it that live bacteria were in action and 
consequently antibodies were being stimulated. 

Of 59 patients who had a + + to + + + 4- positive fixation test 4 to 6 months 
after normal temperature: 

19 ran a fever for less than 4 weeks. 
31 " " " " 5 to 8 weeks. 
9 " " " " longer than 2 months. 

For comparison, of 59 patients who gave a negative fixation test 2 to 3 
months after normal temperature: 

29 ran a fever for less than 4 weeks. 
26 " " " " 5 to 8 weeks. 
4 " " " " longer than 2 months. 

The patients who ran a longer fever course appeared more prone to 
develop a lasting complement fixation test. Still, the length of the 
fever course alone cannot be considered the deciding factor, as there 
were many patients with a prolonged fever who gave a negative com- 



86 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

plement fixation test, and some who ran a very short illness who 
nevertheless showed many fixation antibodies. 

3. Severity of Disease. — As has been said before, the severity of the 
illness of our patients was considered entirely separate from the length 
of the disease, and was graded on a -f- + + + scale. The + + + + pa- 
tients all died. 

Of the 59 cases with a positive complement fixation test 4 to 6 months after con- 
valescence: 

3 were graded — 
37 « « _|_ 

15 " " + + 

4 « « +++ 

or a total of 79 plus. 

Of the 59 cases who were negative at the first examination: 

5 were graded — 
42 " " + 

7 " " + + 
5 " " +++ 
or a total of 71 plus. 

From these figures, it seems as if the severer cases evidenced a 
greater percentage of positive complement fixation tests. On the 
other hand, severity of disease alone cannot be taken as the criterion, 
since it is seen from the above statistics that there are many very 
mild cases which developed lasting complement fixation tests, and vice 
versa many sick cases who are negative early during convalescence. 

4. Relapses and Recrudescences. — The relationship which relapses 
and recrudescences bear to the stimulation of complement fixation 
antibodies was considered apart from either the length or severity 
of the illness. It was thought that the patients who have such setbacks 
usually go through a longer and severer infection and consequently 
complement fixation tests would be more prone to remain positive for 
a prolonged period of time. For once, logical assumption found 
corroboration in statistics. Of 17 patients who suffered relapses, 16 
were positive for 2 to 3 months, and 14 continued positive for 6 months 
or longer after normal temperature. It is interesting to note that the 
only patient who was negative had 3 relapses and finally died with 
typhoid bacteria still in the gall bladder (possibly a complete lack of 



A. L. GARBAT 



87 



immunizing power). Of 14 patients with recrudescences, 9 showed a 
lasting complement fixation test. Thus, out of 31 patients with 
either recrudescences or relapses, 25, or 80 per cent, continued with 
abundant complement fixation antibodies for many months after 
convalescence. 

5. Complications. — It was assumed that patients with true typhoid 
complications, i.e. those caused by Bacillus typhosus and not a 
secondary invader, have a greater number of bacteria or toxins to 
cope with, and therefore would be more likely to combat the increased 
infection by the production of a greater number of antibodies. Such 
conditions as Staphylococcus furunculosis or adenitis, nephrolithiasis, 
chronic bronchitis, etc., were not included in these statistics. Of 31 
cases which had a complication due to the typhoid bacillus, 23, or 74 
per cent, showed a positive fixation test which continued for many 
months after complete convalescence (Table XXXVI). 

TABLE XXXVI. 



Pleuritis 

Typhoid spine 

Neuritis 

Cholecystitis. . 

Parotitis 

Hemorrhage . . 
Appendicitis . . 



Complement 
fixation test. 


No. 

positive. 


No. 
negative. 


1 




1 


1 


1 




5 


2 


1 




4 


1 


1 





Nephritis. . 
Periostitis. , 
Psychosis.. 
Phlebitis. . . 
Pneumonia 
Perforation 



Complement 
fixation test. 



No. 
positive. 



No. 
negative. 



The Complement Fixation Test in Carriers, 

The relationship between the typhoid carrier state and the presence 
of complement fixation bodies is of extreme importance. It is best 
to discuss the findings in the temporary and permanent carriers 
separately. 

For the temporary carriers, the statistics are based upon patients in 
whom the bacteria in the urine or stool persisted at repeated examina- 
tions. Cases with an occasional presence of the typhoid bacillus in 
the excreta were almost the rule and were therefore not included in 
the analysis. 



88 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

In 10 urine carriers, complement fixation persisted strongly positive; 
in 4 for 2 to 3 months, and in 6 for 4 to 6 months, after convalescence; 
in 9 of these 10, the test remained positive for months after the carrier 
state cleared up. 

Of 3 feces carriers, 2 were positive for 4 months, and 1 negative 
early during convalescence. Contrary to expectation the latter be- 
came a permanent bile carrier. 

Of 19 patients with typhoid bacilli both in the urine and stool, 15 
continued to show strong complement fixation for 6 months and 
longer after convalescence, while 4 were negative 2 months after 
normal temperature. The complement fixation tests remained posi- 
tive after the bacteria had disappeared. 

Taking all these classes together, we found that out of 32 typhoid 
carriers, 27, or 85 per cent, showed a constant and strong fixation re- 
action, while in 15 per cent the fixation antibodies disappeared early, 
although the carrier state continued. 

Vice versa, in almost all of the temporary carriers with a strongly 
positive complement fixation, the antibodies remained demonstrable 
long after the bacteria had disappeared. 7 

As for the permanent or chronic carriers, scanty references are found 
in the literature regarding their complement fixation bodies. 

Schone (81) reports the findings in 3 carriers, only 2 of whom 
were chronic carriers. The reaction was positive in one of 10 J years 
duration and negative in the other of 2 years duration. The author 
(77) reported a urine carrier of 1 year standing with a positive re- 
action. Henderson-Smith (82) demonstrated these bodies in the sera 
of 2 carriers both of whom gave negative Widal tests. 

Of 4 chronic (probably permanent) bile carriers of 8 to 9 months 
duration, only 3 continued strongly positive. The fourth (mentioned 
above) was negative 2 months after normal temperature. In 1 
patient who was a very marked bile carrier and who was cured by 
cholecystectomy 4 months after the acute illness, the complement 
fixation bodies were still present in great numbers 8 months after 
operation. 

7 It was difficult to determine how long the test remained positive as all the 
the patients were transferred to ports of debarkation. 



A. L. GARBAT 89 

3 chronic carriers were examined by the author for Lieutenant- 
Colonel Nichols with the following results: 

1. Typhoid fever in Jan., 1918; carrier condition results; cholecystectomy in 
Nov., 1918; cured; complement fixation strongly positive in Feb., 1919. 

2. Typhoid fever in 1910; carrier condition results; cholecystectomy in 1918; 
carrier condition continues; complement fixation strongly positive in Feb., 1919. 

3. Typhoid fever in 1905; carrier condition results; cholecystectomy in 1918; 
carrier condition continues; complement fixation =±= in Feb., 1919. 

Resume. — From an analysis of the above discussions, the writer has 
formed the conclusion that the fixation test is dependent directly upon 
the number of typhoid bacteria with which the patient is infected, 
and the length of time that they remain in the system. The greater 
the number or the longer the time, the stronger and more lasting will 
the test be. A large number of bacteria may or may not, however, 
mean a sick patient, a long disease, a relapse, a complication, or a 
carrier state. Other factors such as the virulence of a particular 
bacillus, the resistance of the individual, etc., which we cannot esti- 
mate, bear additional influence. 

Therefore one cannot foretell whether a particular patient will per- 
sist with a. complement fixation test or not. If from the clinical 
course of the disease or the laboratory findings, one has reason to 
feel that the patient is infected with a large number of bacteria and 
over a prolonged period of time, one may assume that complement 
fixation will continue positive for a long time, even years after con- 
valescence. This is usually the case in long continued illness, or with 
relapse or complication or carrier condition. Reversely, the continued 
positive test may be the first indication of the systemic response to a 
large number of typhoid bacteria. 

With this hypothesis in mind, experiments were undertaken in 
rabbits in order to reproduce some of the bacteriological factors men- 
tioned above as influencing the production and persistence of the 
complement fixation test. 

Experimental Studies to Prove the Origin of the Complement Fixation 

Bodies, 

Experiment 1. — The first set of experiments attempted to present conditions 
similar to those existing in man after prophylactic immunization. 2 rabbits 



90 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

were inoculated subcutaneously with ordinary typhoid vaccine (Rawling strain). 
The dose of vaccine used (30 million bacteria) bore the same approximate pro- 
portion to the dose in man (2,500 million) as did the weight of the rabbit (2 
pounds) to that of man (150 pounds). 

Result. — Antibodies were not produced in sufficient numbers to be demon- 
strated by complement fixation tests at intervals of 2, 4, 6, 8, and 12 weeks after 
inoculation. 

The agglutination test was partially positive in the serum dilution of 1 to 50 
1 week after inoculation, but negative after that. 

These complement fixation results tally with the findings in man 
after prophylactic inoculation. 

Experiment 2. — In the second set of experiments 5,000 million bacteria were 
given to the rabbits subcutaneously. This was approximately 150 times the dose 
used in man on the basis of weight comparisons. 

Result. — Even this excessive dose did not stimulate sufficient complement 
fixation bodies to give the test. 

Agglutinins were readily demonstrable in serum dilution 1 to 50 1 week after 
immunization. 

Experiments 3 and 4. — The first two experiments were repeated, but instead of 
the ordinary vaccine, the lipoid vaccine was used both in the small and large 
dosage employed in Experiments 1 and 2 respectively. 

Result. — Complement fixation bodies were not produced in sufficient numbers 
to give the reaction. 

Likewise, 17 nurses who received the triple lipoid vaccine never showed comple- 
ment fixation bodies. 

Experiment 5. — This experiment aimed at producing a bacteremia of a com- 
paratively mild type, and for a short period of time, by means of the repeated 
intravenous injections of living bacteria. Controls were also made in other 
rabbits by using the same number of bacteria but killed by heat. The dosage 
employed in these experiments was similar to the smaller doses used in the former 
experiments and comparatively the same as are used in human beings for prophy- 
lactic immunization. Rabbit 1 received 250 million dead typhoid bacilli in- 
travenously on 3 successive days. Rabbit 2 received 500 million dead typhoid 
bacilli intravenously on 3 successive days. Rabbit 3 received 250 million living 
typhoid bacilli intravenously on 3 successive days. Rabbit 4 received 500 
million living typhoid bacilli intravenously on 3 successive days (Table XXXVII). 

Thus it is noted that complement fixation bodies were readily pro- 
duced in the serum of rabbits if a sufficient number of bacteria re- 
mained in the system long enough. The greater the number of 
typhoid bacilli, the more marked was the fixation. Living bacteria 
produced a serum richer in antibodies than did inoculation with dead 
bacteria. 



A. L. GARBAT 



91 



TABLE XXXVII. 





Rabbit 1. 


Rabbit 2. 


Rabbit 3. 


Rabbit 4. 


Quantity of 

serum (heated) 

used for 

fixation. 


13.2 

4-1 

si 

M 


hi 

13.2 
P 

E.e 


Ul 

4> . 

13.2 
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18 

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2.5 


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o o 
£.5 


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4> . 

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M 

V . 

ea.O 


14 

V . 

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13.2 

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n 

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■* 


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1-4 


es 


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0.05 


++ 


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* 


+ 


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+ H- 


++ 


4- + 


++ 


+ + 


+ + 


0.02 


± 


+ 




+ 


+ + 


+ 


+ + 


++ 


+ + 


++ 


+ + 


+ + 


0.01 


± 


+ 




+ 


+ 


+ 


4- + 


+ 


+ + 


++ 


+ + 


+ + 


0.005 





+ 




db 


+ 


+ 


+ 


+ 


+ 


++ 


+ 


+ + 


0.002 





± 




=fc 


+ 


rb 


db 


± 





+ 


± 


+ 


0.001 










db 


=b 





• =b 


d= 








db 


+ 


0.0005 













=b 





i 











± 


± 



+ + = complete fixation; + = partial fixation; =b = slightest fixation; 
= no fixation. 

* Tests were spoiled. 

Experiment 6. — This last experiment was similar to Experiment 5, but the do- 
sage of vaccine employed was 6 to 30 times greater than in the latter experiment. 
Rabbit 1 received 1,500 million living bacteria intravenously on 3 successive days. 
Rabbit 2 received 1,500 million living bacteria intravenously on 7 successive 
days. Rabbit 3 received 7,500 million living bacteria intravenously on 3 suc- 
cessive days (Table XXXVIII). 



TABLE XXXVin. 





Rabbit 1. 


Rabbit 2. 


Rabbit 3. 


Quantity of 

serum (heated) 

used for 

fixation. 


u 

13.2 


hl 

V . 

13.2 

03 rt 
g ° 

.s 


<u . 

*-' c 

13.2 

p 

E.c 


u 

4> . 

13.2 

§8 
E.S 


a 

H 


ii 
«».2 

oi rt 

go 


it . 
ee.o 

E_c 


1- 

°5.2 

JS5 

II 

E.S 


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v . 

13.S 
^1 


efl.O 

05^ 
« y 

g o 

.5 


V . 

13.2 

O X 

e| 


hi 
<u . 

«.2 

s.s 




<r> 


«N 


*-* 


CN 


<*5 


es 


^1 


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«*» 


CN 


•^^ 


CN 


cc. 

0.05 


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+ + 


+ + 


+ + 


+ + 


+ 


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+ + 


4- 


++ 


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0.02 


+ + 


* 


+ 


+ + 


+4- 


+ 


++ 


H- + 


+ + 


4- 


++ 


++ 


0.01 


+ + 


* 


+ 


+ + 


++ 


+ 


+ 


+ + 


+ + 


+ 


++ 


++ 


0.005 


+ 


* 


+ 


+ 


++ 


+ 


+ 


4- + 


+ 


+ 


++ 


++ 


0.002 





+ 


+ 


+ 


+ 


+ 


dh 


± 


d= 


dh 


+ 


+ 


0.001 





-f 


zk 





± 


+ 


db 


± 





=fc 





+ 


0.0005 





+ 


db 








+ 


dfc 








± 





+ 



Tests were spoiled. 



92 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

Here again it is proved that the greater the number of living 
bacteria in the circulation, the greater the number of fixation bodies 
formed. With the same number of bacteria injected, the longer 
they remain in the blood the more numerous are the complement 
fixation bodies that are stimulated. 

Discussion. — While the author realizes that especially in the study 
of typhoid fever one should not draw conclusions too readily from 
experimental results in rabbits, still the problems presented here 
dealt more with the immunologic reactions to the presence of bacteria 
than with the anatomical or clinical effects caused by them. 

These experiments should be repeated in a larger series of animals 
in order to be certain that our results were not dependent upon the 
exceptional reactions of a few animals. As far as we have gone, how- 
ever, the experiments substantiate our hypothesis based upon clinical 
analysis of the cases of typhoid fever; namely, that the persistence of 
the complement fixation test depended upon the actual number of 
living typhoid bacteria that invaded the system and the length of 
time they remained there. Already in 1916 (78) we offered this 
explanation for the almost constant presence of the reaction during 
typhoid fever and the almost constant absence after prophylactic 
immunization. During typhoid fever, one is inoculated with 
live bacteria instead of organisms killed by heat, and with a com- 
paratively much greater number of bacteria than in prophylactic 
immunization. 

Comparison between Widal Test and Complement Fixation Test during 

Convalescence. 

It has already been established (77) that during the acute stage of 
typhoid fever, the complement fixation test bears no direct relation- 
ship to the agglutination test. This also holds true during con- 
valescence. Comparative tests made during the first 2 to 3 months 
after normal temperature showed : 

89 cases with positive complement fixation test and positive Widal test. 
11 " " " " " " " negative " " 

42 " " negative " " " " positive " " 

13 « " " " " " " negative " " 



A. L. GARB AT 



93 



It is important to remember that the complement fixation bodies 
may persist very much longer than the agglutinins. This is evident 
from Table XXXIX. 



TABLE XXXIX. 





Widal test. 


Complement 
fixation test. 


Time of 


Name. 


Dilution. 


examinations 
after normal 
temperature. 




1:50 


1:100 




Fricke 


+ 

± 

± 
± 


± 


+ + + + 
+ + + + 

+ + + 
+++ + 

+ + 
+ + + + 
+ + + + 
+ + + + 


months 
5h 


Ma jorowski 


5 


Heinricksen 


5 


Gottschalt 


3* 

5 


Kreussler 


Hohlweg 


51 


Muza 


5 


Steinhoff 


5 







The Complement Fixation Reaction as a Diagnostic Test during 

Convalescence. 

From a diagnostic standpoint, the complement fixation test made 
for the first time during convalescence, was of aid in several classes 
of cases. They were: 

1. Cases That Were Diagnosed as Typhoid Clinically but Had No 
Other Laboratory Corroboration for That Diagnosis (Table XL) . — This 
included 15 patients in whom: (a) Widal lest was of no help, because 
of antityphoid inoculations just previous to the onset of the illness. 
(b) Blood cultures were negative, probably because the patients were 
received in the third and fourth week of the disease, (c) The urine 
and feces showed no typhoid bacteria. The complement fixation test 
in all of these patients was strongly positive (in 13 it was + + + + ; 
inl,+ + + ;inl,++). A-f- reaction was not considered sufficiently 
specific when the complement fixation test alone was to be the 
support for the diagnosis. These cases comprised 9.2 per cent of our 
typhoid patients; in them the positive complement fixation reaction 
was the only laboratory test which corroborated the definite clinical 
diagnosis of typhoid fever. 



94 



TYPHOID CARRIERS AND TYPHOID IMMUNITY 





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96 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

It is interesting that most of these patients suffered from com- 
paratively mild typhoid infections. On the basis of a -f + -f--h 
scale for estimating the severity of the disease, 3 of these patients were 
classed as negative, i.e. were only very slightly sick; 11 were +; and 
only 1 was + + . It must be noted from the table that the test was 
first done as late as 39 to 90 days (1 to 3 months) after the beginning 
of normal temperature. If the tests had been done earlier, the posi- 
tive diagnosis could have probably been established in 10 other cases 
(Table XLI) which were diagnosed typhoid clinically but had no 
laboratory corroboration whatever. Even the complement fixation 
reaction was negative; but, as is seen by the table, the tests in these 
cases were not started before the 2nd month of convalescence. In 1 
case it was done on the 31st day after normal temperature, in 4 during 
the 10th or 11th week, and in 5 during the 12th or 13th week after the 
absence of fever. This group of cases is collected to show that while 
we have a great many laboratory methods at our disposal for es- 
tablishing the existence of typhoid fever, 6 per cent of the typhoid 
cases remained unconfirmed by the usual methods. Had it been 
possible in our epidemic to perform the complement fixation reaction 
earlier during convalescence, or during the acute stage of the disease, 
it is certain that the clinical diagnosis could have been confirmed in 
most of the cases. This would have made about 15 per cent of 
typhoid cases where the complement fixation test would have been 
the only laboratory means of diagnosis. 

2. Cases That Were Diagnosed as Typhoid Clinically andGaveaWidal 
Reaction as the Only Positive Laboratory Test {Table XLI I). — This 
class included 6 patients and all of them had a + + + + positive 
complement fixation test. While a positive Widal test, properly per- 
formed and controlled, is sufficient for the diagnosis of typhoid fever, 
one is usually more satisfied when another corroborative test is at hand. 
This is especially so in epidemics similar to this one, where the history 
of previous inoculation is obtained from a great percentage of the 
patients, and where it is perfectly possible that some patients deny 
inoculation while others forget about it at the time of questioning. 
If one adds the number of patients in this series to the number in 
Class 1, we get 13 per cent of typhoid cases where the complement 
fixation test was of direct help in establishing the laboratory 
diagnosis. 



A. L. GARBAT 



97 



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98 



TYPHOID CARRIERS AND TYPHOID IMMUNITY 



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A. L. GARBAT 



99 



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100 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

3. Cases in Which Them Was a Possible Doubt but Which Clinically 
Did Not Give the Impression of Typhoid Fever, and in Which the Com- 
plement Fixation Test Was Negative. — The Widal test was of no aid 
in this group because of previous inoculations; the blood cultures 
were dither negative or were not made because the patients first came 
under observation when the acute stage of the disease was over and 
the temperature was normal. There were 5 such instances; the 
diagnoses were, meningitis, hemiplegia, pleuropneumonia, reactions 
following inoculation (2 cases) (Table XLIII). All of these had 
negative fixation tests. 

Summary. — Adding the number of patients in these 3 groups, 36, 
one finds that the complement fixation test gave valuable information 
in 21.5 per cent of the cases diagnosed as typhoid fever during a 
typhoid epidemic amongst patients only partly, entirely, or not at 
all immunized by previous inoculation. 

Especially with the more generalized use of antityphoid inocu- 
lations, some test is needed to replace the agglutination reaction when 
the blood culture and other methods are negative. The fixation 
reaction aims to supply this demand. The Dreyer agglutination 
method has also been advocated with this object in view (S3). 

Technique of the Complement Fixation Tests. 

The technique employed in performing the complement fixation 
tests is the same as that reported in the author's original publication 
(77) . It will be reviewed in part in order to discuss several important 
additional observations. 

Antigen. — The preparation of the antigen is the most important element in the 
reaction. The author's method followed the directions of Wasserman and 
Citron (84) for preparing artificial aqueous aggressins. Cultures are grown for 24 
hours upon agar slants or plates (Kolle's flasks are preferable). The growth is 
washed off with sterile distilled water, about 1 cc. to an agar slant. The total 
emulsion is kept in a hot-water bath at a temperature of 60-65°C. for 24 hours, 
then transferred to a strong bottle and shaken vigorously with the aid of glass 
beads for 24 hours. The bacteria are thus thoroughly broken up. The mixture is 
next centrifugalized for a long time (4 to 8 hours, depending upon the total quan- 
tity) until all the bacteria have sunk to the bottom and the supernatant fluid is 
absolutely clear. The latter is carefully pipetted off, and can be preserved for 
about 6 to 8 months in sealed tubes, not exposed to sunlight or room tempera- 



A. L. GARB AT 



101 



ture. Sterile precautions must be taken throughout the preparation. The object 
of using a total small quantity of distilled water is to eliminate the hemolysis of 
red blood cells, which may be occasioned by employing large doses of antigen in 
the test. 

It is best to titrate the strength of the antigen about 1 week after its prepara- 
tion as at the end of this period its titer usually remains unchanged. Varying 
quantities of antigen are mixed with the constant units of complement, hemolysin, 
and red cells (sheep system), and those amounts are determined which do not of 
their own accord inhibit hemolysis (Table XLIV) . 



TABLE XLIV. 
Titration of Antigen. 



Typhoid 
antigen. 


Complement. 


Hemolysin. 


Red blood 
cells. 


Saline. 


Result. 


cc. 


cc. 


cc. 


cc. 


cc. 




0.2 


0.5(1:10) 


0.5(1 


1,000) 


0.5(1:20) 


Up to 2.5. 


No hemolysis. 


0.1 


0.5(1:10) 


0.5(1 


1,000) 


0.5(1:20) 




u u 


0.5 


0.5(1:10) 


0.5(1 


1,000) 


0.5(1:20) 




Complete hemolysis. 


0.025 


0.5(1:10) 


0.5(1 


1,000) 


0.5(1:20) 




u « 


0.0125 


0.5(1:10) 


0.5(1 


1,000) 


0.5(1:20) 




it U 


0.00625 


0.5(1:10) 


0.5(1 


1,000) 


0.5(1:20) 




(i a 



In accordance with the summation law of Weil and Nakajama (85), the dose 
of antigen to be employed in complement fixation experiments is represented by 
one-half of the maximum quantity of antigen that does not of itself bind comple- 
ment; that is, in the above instance one-half of 0.05 cc, or 0.025 cc, or 0.5 cc of 
a dilution 1 to 20. This unit of antigen is then tested with a known typhoid serum 
to prove that complement fixation is possible. 

In a recent article (86), studying the comparative antigenic sen- 
sitiveness of nine typhoid antigens each prepared in a different way, 
Matsumoto showed that the method of preparation has a decided effect 
upon the occurrence and degree of complement fixation tests. In his 
experiments the antigen similar to the author's, prepared from the 
filtrate of typhoid bacilli autolyzed in distilled water aided by heating 
at a high temperature, proved least antigenic. Mainly immune sera 
from rabbits were used for this differentiation and no series of typhoid 
patients or inoculated persons were studied. At first sight this 
would speak against the use of such distilled water extract antigens. 
We do not, however, consider this lessened sensitiveness a disadvan- 
tage if the test is to differentiate between a serum from a patient with 



102 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

an active typhoid fever and a serum from a person inoculated with 
typhoid vaccine. In the former individual, the antibodies stimulated 
by the great excess of typhoid bacilli in the system have been produced 
in such great numbers that they readily give complement fixation 
even with a less sensitive antigen. On the other hand, in inoculated 
persons the number of complement fixation bodies are so few that 
they do not react with an antigen which is not highly sensitive. In 
other words, for this purpose it is better to have the antigen not too 
sensitive. 

The distilled water extract antigen described by Matsumoto is 
probably less sensitive than the similar antigen of the author's 
(Garbat), for Matsumoto places the suspension of bacilli in a water 
bath at 80°C, while the writer does not allow a temperature over 
65°C. Higher temperatures interfere too much with antigenic 
properties. 

Matsumoto also noticed that inactivating the human serum at 
56°C. for 30 minutes causes a marked reduction in the degree of 
complement fixation. In the writer's studies, all the sera examined 
were previously heated thus. Just as with the reduced sensitiveness 
of the antigen, the writer believes that the reduction in sensitiveness 
of the serum by its being heated is not a disadvantage when one 
wishes to differentiate between a serum from an inoculated person 
and the serum from a typhoid patient. 

As has been said before, a typhoid fever serum usually has an excess 
of antibodies and even a slight diminution in their number by heating 
will still leave sufficient for the reaction. Done in this less sensitive 
way, as recommended by the author, the complement fixation test 
when positive is all the more specific for active typhoid fever. 

If it should be determined by the study of a large number of cases 
that the more sensitive antigens of Matsumoto react not only with 
the sera from cases of typhoid fever but also with the sera from inoc- 
ulated persons, then sensitive antigens combined with unheated 
serum will have a limited use only in patients who are suffering from 
a suspicious typhoid illness but who have with certainty not been 
inoculated, while our less sensitive antigen combined with heated 
serum will be employed in other suspicious typhoid cases which may 
have received typhoid inoculations. Then, too, it will have to be 



A. L. GARBAT 103 

shown that the more sensitive antigens do not react with sera from 
patients with high fever suffering from acute infections other than 
those of typhoid origin. The less sensitive typhoid antigen has proved 
specific. 

As many different typhoid strains should be employed in the pre- 
paration of the antigen as possible. A highly polyvalent antigen is 
an element which accounts for a higher percentage of positive com- 
plement fixation tests (77). Antigens prepared from autogenous 
strains give the best fixation. The antigen used in the present 
study contained 15 strains out of a total of 45 strains isolated. It is 
probable that all the typhoid bacilli were the same, since they were 
derived from the same epidemic. We were able to employ an auto- 
genous antigen because the fixation tests were started only during 
convalescence. 

Comparative fixation tests done in 17 patients with 2 different 
antigens, 1 from the autogenous strain and 1 from the Rawling strain, 
showed 10 positive with the autogenous antigen and only 4 positive 
with the Rawling antigen. There was no cross fixation with a para- 
typhoid antigen. 

Complement. — In the original publication (77), a fixed dose of com- 
plement, that is 0.05 cc. of the mixed serum from several guinea pigs, 
was employed for the J quantity system. This technique has not 
been changed. Titration of complement was intentionally omitted 
because it has not as yet been worked out whether titration of com- 
plement so that no excess is used, may not make the reaction too 
delicate and thus non-specific. A patient with typhoid fever usually 
produces so many antibodies that the fixation test is not overshadowed 
by a slight excess of complement. Water bath incubation for 1 hour 
was used. 

Hemolytic System. — The sheep corpuscles system was continued for 
the same reason. Similarly, the natural antisheep amboceptors in 
human serum were not taken into account as is done in the Wasserman 
test. 2 units of hemolysin were used. After the system was added, 
the tests were read in 20 minutes. 



CONCLUSIONS. 

I. 

1. This report is based upon the study of a typhoid epidemic in- 
cluding 183 patients, and probably arising from polluted drinking 
water. Laboratory tests were performed in only 164 cases. 

2. The typhoid illness was divided into "the acute fever stage" 
and " convalescence, " the first day of the persisting normal tempera- 
ture being used to separate the two periods. 

3. The Endo medium, properly prepared, is very satisfactory for 
distinguishing the typhoid and the colon bacilli. 

II. 

4. Feces cultures employed for detecting the presence of typhoid 
bacteria in the intestines, fail in 15 per cent of typhoid carriers. 
Direct examination of the bile by duodenal cultures is the only ac- 
curate means for the detection of the carriers. In 15 per cent of 
typhoid convalescents, typhoid bacilli may be discovered in the bile 
after 3 consecutive stool cultures have been negative and they are 
not destroyed in the intestines but merely escape detection by stool 
examination. 

5. Feces cultures should not, however, be entirely discarded because 
of the existence (although very rare) of pure intestinal carriers, in 
which typhoid bacilli occur in the stool and not in the bile. One such 
definite intestinal carrier is reported. 

6. An absolutely safe indication of the complete absence of typhoid 
bacteria in the intestinal tract would be offered by 2 consecutive 
negative bile cultures and 2 consecutive negative feces cultures. No 
special interval of days between these examinations is required. 

III. 

7. 32 per cent of typhoid patients become feces carriers. Of these, 

28 to 29 per cent are temporary carriers while 3 to 4 per cent become 

permanent carriers. 

104 



A. L. GARBAT 105 

8. Of the temporary carriers, 

17.5 per cent are carriers for 1 month. 
8.0 " " " " " 2 months. 

■7 r\ it tt i( tc it -2 a 

9. Three distinct types of feces carriers have been found, according 
to the original source of the infection: (a) liver, (b) gall bladder, (c) 
intestinal. In the first two only are the bacilli transmitted by the 
bile. Combinations of these types may result, if the carrier state 
continues. 

10. During early convalescence, one may attempt by stool cultures 
to differentiate between bile carriers (liver and gall bladder) and intes- 
tinal carriers. In the intestinal carriers, the bile cultures show no 
typhoid organisms, while the stool cultures show almost a pure growth 
of the bacilli; the bacilli appear in the stool at the beginning of 
convalescence and continue there persistently. 

In the bile carriers, the feces cultures may show only few typhoid 
colonies, or even none at all, while the bile shows typhoid bacilli 
usually in pure culture. 

11. As an explanation for the origin of bile carriers, ascending in- 
fection of the gall bladder or liver from the intestines is possible, al- 
though the usual path is by way of the blood and a descending route. 

12. Cholecystectomy is curative in pure gall bladder carriers only. 
Liver and intestinal carriers are uninfluenced by cholecystectomy. 

13. Instead of cholecystectomy as the routine operation, in carriers 
cholecystectomy should be combined with hepatic drainage both for 
diagnostic and therapeutic purposes. Long continued drainage of 
the hepatic duct should be carried out in liver carriers. 

IV. 

14. No factors can be cited as definitely predisposing to the carrier 
condition. 

15. Patients who present symptoms of cholecystitis or cholelithiasis 
during the course of the typhoid illness, usually become carriers, but 
not all the carriers necessarily present symptoms referable to the gall 
bladder during the acute illness. 



106 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

16. Surgical measures to remove the carrier state should be under- 
taken very much earlier in those carriers who have had a complicating 
cholecystitis. 

17. Cholelithiasis following typhoid fever may only be associated 
with and not necessarily induced by the typhoid bacillus. On the 
other hand, gall stones of unusually large size may be formed during 
the typhoid illness and originate from the typhoid bacillus. 

V, Part A. 

18. The use of solid media alone (Endo plates) for detecting typhoid 
bacilli in urine is inadequate. A 24 hour growth in broth is first 
necessary before plating. 

19. The excretion of typhoid bacteria in the urine is of an inter- 
mittent character. The urine may change from a specimen with no 
bacteria to one with very many bacteria within several hours. 

20. It is misleading to consider the urine of patients free from 
typhoid bacteria on the basis of 3 consecutive negative exami- 
nations at 6 day intervals; such a rule fails in 20 to 25 per cent of 
urine carriers. 

21. A negative culture in broth from a 24 hour specimen of urine 
sterilely collected is the only safe guide. 

V, Part B. 

22. The urine is as important a factor as the feces in the spread of 
typhoid fever. 

23. 49 per cent of patients present typhoid bacilluria during con- 
valescence. 

24. There is no relationship between typhoid bacilluria and the 
specific gravity, acidity, or albumin content of the urine. 

25. Bacilluria is most frequent during the first week after normal 
temperature, when as many as 63 per cent of cases show typhoid 
bacilli in the urine. 

26. 6.7 per cent of all typhoid cases, or 13.6 per cent of all cases of 
bacilluria, remain positive for 1 to 2 months after the absence of 
fever. In only 1.2 per cent of all typhoid cases, or 2.5 per cent of all 
positive cases, does the bacilluria continue for 2 to 3 months. 



A. L. GARBAT 107 

27. No definite explanation can be given for the intermittency with 
which the typhoid bacilli are excreted. It was suggested that an 
infection in the pelvis of the kidney or its calyces might account for 
the condition. Under these circumstances, the pelvis of the kidney 
bears the same relation to the kidney as does the gall bladder to the 
liver. 

VI. 

28. In 30 per cent of typhoid patients, the complement fixation 
bodies disappear from the blood by the 2nd month of convalescence, 
while 40 per cent of patients still show a positive fixation at the end 
of 6 to 8 months after the temperature has become normal. 

29. A persisting complement fixation test is dependent directly 
upon the number of bacteria which have invaded the body and the 
length of time they remained there. 

30. In 80 per cent of patients with recurrences or relapses, and 85 
per cent of carriers, a strong complement fixation test persists. How- 
ever, not all carriers, not even all permanent ones, necessarily continue 
to give the fixation test. 

31. In 9.2 per cent of our cases of typhoid fever the complement 
fixation examination was the only laboratory test which confirmed the 
clinical diagnosis of typhoid fever; the reaction was performed for the 
first time as late as 1 to 3 months after the onset of normal tempera- 
ture. The test was of valuable assistance in 21.5 per cent of our 
cases. 

The author again desires to express his appreciation to Colonel 
F. F. Russell for his constant cooperation and interest in this problem. 
Thanks are also due to the commanding officers at U. S. A. General 
Hospital No. 12, Lieutenant-Colonel William H. Smith and Lieutenant- 
Colonel J. B. McCreary, who greatly facilitated the work by placing 
the clinical material at the author's disposal and granting him all the 
required laboratory equipment and assistance. Without this 
assistance this study could not have been completed and therefore 
sincerest thanks are due to Sergeant Paul Piel for his ever ready 
aid and his patient and untiring efforts with the duodenal cultures 
and urine work, as well as to Lieutenant Schleussner, Lieutenant 
Whiting, Corporal Case, Corporal Rudolf Piel, Miss Nichols, Miss 
Warner, Sergeant Owens, and Private Wintermeyer. 



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110 TYPHOID CARRIERS AND TYPHOID IMMUNITY 

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